The author of the bestselling book "The Plantagenets" picks up the story of the English crown where his last book left off. It describes how the longest-reigning British royal family tore itself apart and was replaced by the Tudors.
The deadline for signing up for health insurance under the Affordable Care Act expired at midnight last night. A surge in traffic on Healthcare.gov caused some problems for the website. But health officials say the last-minute sign-up rush could put the total number of enrollees beyond the 6 million that had been predicted by the Congressional Budget Office. Republican leaders continue to criticize the ACA. But supporters say the White House is vindicated by the enrollment numbers. Diane talks with a panel of health care experts about the first phase of the new health insurance law and challenges that lie ahead.
- Juliet Eilperin White House correspondent, The Washington Post.
- Susan Dentzer senior policy adviser, The Robert Wood Johnson Foundation, and on-air analyst on health issues, PBS NewsHour.
- Mary Agnes Carey senior correspondent, Kaiser Health News.
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. After a troubled start last fall, the first enrollment period of President Obama's signature health insurance law came to a close last night. A rush to purchase insurance on healthcare.gov before the deadline caused problems to the site. But those who had difficulties will be getting an extension.
MS. DIANE REHMJoining me to talk about the exchanges, and to answer your questions about next steps: Susan Dentzer of The Robert Wood Johnson Foundation, Mary Agnes Carey of Kaiser Health News, and Juliet Eilperin of The Washington Post. I do invite your questions, your comments. Give us a call at 800-433-8850. Send us an email to firstname.lastname@example.org. Feel free to follow us on Facebook or send us a tweet. Well, welcome to all of you.
MS. SUSAN DENTZERGreat to be with you, Diane.
MS. MARY AGNES CAREYThanks.
MS. JULIET EILPERINGreat, Diane.
REHMThank you. Susan Dentzer, what do we know about the numbers so far?
DENTZERWell, what we know is that the administration says we are now on track. The nation is now on track to have signed up 7 million people.
DENTZERSeven million people, on track, we should say, to be verified -- probably more later today -- 7 million people in this first open enrollment period under the Affordable Care Act. And that is the people who have signed up on the health insurance exchanges, the marketplaces, both the federal exchange, healthcare.gov, as well as the state-based exchanges. And there are 15 of those, 14 states and the District of Columbia.
DENTZERWe also know that a large number of people have been told that they are eligible for Medicaid. A total of 9 million people have been told they are eligible for Medicaid, not for private coverage obtained through the exchanges. So some portion of those people presumably have gone on now and signed up for Medicaid. We don't know the absolute number though at this point.
REHMSo, Mary Agnes, in these last few weeks, there's been a huge surge.
CAREYThey expected this. They expected people would wait till the March 31 deadline.
REHM'Cause people procrastinate, yeah.
CAREYPeople procrastinate. And also there's been a lot of confusion out there about the enrollment period, about the penalties, about the subsidies. Does my state operate an exchange or not? Is my state, you know, expanding Medicaid or not? So they anticipated this. They were ready for it. They did have some outages yesterday. But overall they had done enough fixes. We had a very different experience at the end of the enrollment period than we had on Oct. 1 when it started and the website had so many problems.
REHMSo, Juliet, do we know the breakdown, sick people, not sick people, young people, older people? When will we know those numbers?
EILPERINWe don't know those numbers yet. We're hoping that next -- well, actually, I would say later in April. Now that we're in April, we should get some sort of breakdown on this. We certainly know, when talking anecdotally, whether you're talking to insurance executives, state exchange folks, navigators, everyone, there was an uptick in the number of young people who were signing up.
EILPERINThere was, for example, they made inroads in having more Latinos sign up, and they were optimistic that that would help the risk pool because they were disproportionally uninsured. And so they thought that those would not be just the people who signed up early on, who were older and sicker. So -- but the absolute mix, that's to be determined, and hopefully, in the coming weeks, we'll get a more precise breakdown.
REHMNow, on national television, on Sunday, a Republican senator from Wyoming accused the Obama Administration of "cooking the books." What was he talking about? Is there anything to support his charge, Juliet?
EILPERINWell, I think, you know, he -- they really haven't released some of the specifics that we're hoping about. And it's also particularly hard, as, you know, Mary Agnes and Susan have mentioned, to figure out who was previously uninsured. And so there are so some questions about how many people, for example, had other plans and are switching over because of the law's mandate or how many people were previously uninsured.
EILPERINPart of it is that we don't have quite the level of transparency that we would want. And these numbers need to be scrubbed. And so I think that that's something that there are going to be tons of reporters, as well as advocates and Republican critics, who will be looking for in the weeks to come. But, eventually, we can get an answer to those questions.
REHMWhat about numbers of people who have actually made that first payment, Mary Agnes?
CAREYWe don't know that either officially from the government. Insurers are saying about 80 percent of people have paid. And so that's the typical industry standard. But we don't have an official estimate yet from the Department of Health and Human Services. But, as Juliet noted, this is one of those numbers that everyone is very interested in discovering.
DENTZERAlthough Secretary Sebelius has said it's running 80, 90 percent. Secretary...
REHMEighty, 90 percent.
DENTZEREighty to 90 percent.
EILPERINAnd I think it's worth noting that it really depends on the exchange. Connecticut had been averaging, say, 92 percent, but California was 85 percent. And, again, we would expect it would be lower in the federal exchange.
REHMI want to encourage our listeners to be part of this program. I'm sure many of you have questions. Give us a call, 800-433-8850. One of the issues that I think people are wondering about are the so-called penalties involved, Susan.
DENTZERThat's right. Of course, everyone is mandated now to have health insurance and if not able to be exempted for a number of particular reasons will have to pay a penalty. That will not happen though until people file their tax returns for the 2014 calendar year. So that's next year. April 15 of next year, people will learn, as they fill out their tax return and have to check the box that they either do or do not have health insurance, whether they will have to pay the penalty.
DENTZERAnd the penalty, of course, for an individual in the first year is low. It's either the greater of $95 or 1 percent of household income above the filing threshold, which basically means you take your modified adjusted income, you subtract about $10,000 for an individual, and you would be taxed on that 1 percent of that amount -- very complicated. But more information is available on the IRS website for people who want to delve into the details of it.
REHMI wonder how this differs from, say, the requirement that all of us have automobile insurance. You know, I can remember when that requirement went into effect. It was a huge hue and cry. And now you've got penalties involved here. How serious do you think they are, Mary Agnes?
CAREYWell, if you have to pay the difference of $95 or 1 percent of income, whichever is greater, I think people often forget about the 1 percent. As Susan's talking about, it's kind of a complicated formula. They think about $95. No big deal. I'll pay that. I'm set.
REHMNo big deal, right.
CAREYThat's not the case. And those increase. In 2016, it goes to about $695 or 2.5 percent of income for an individual, whichever is greater. That increases with family size. So, as Susan noted, there are lots of exemptions, lots of ways to get out of it. If you fall into that category, this could be a significant amount of money.
EILPERINAnd I think we've seen -- politically, we saw it on the controversy over if you like your healthcare plan, you can keep it, where there was a small number of Americans, for example -- I mean, although, you know, still we're talking relatively it still ends up being, you know, significant numbers -- but a small number of Americans who lost their plans because they didn't meet the essential benefits requirement of the law.
EILPERINAnd they were a powerful political voice, and they were very upset. I think you certainly could see the same thing. And Democrats are concerned. You'll see a similar dynamic come next year when people are filing their taxes that, regardless of the actual dollar amount, people will be outraged, and they will demand some kind of response from lawmakers.
REHMResponse in what sense?
EILPERINWell, I think, again, Republicans will be certainly hoping this will add fuel to their push to repeal it. And certainly we'll see what happens with, for example, if Republicans control the Senate. There isn't -- you know, I think it's worth noting, in terms of enforcement, the primary way that the IRS will be enforcing this is by withholding from your refund. So if, for example, you paid your taxes and you're not going to get a refund, you actually won't be forced to pay the penalty. So we'll have to see how -- you know, what the numbers are like.
EILPERINBut you'll certainly still see people upset, regardless of whether there's a practical solution to this problem.
REHMDo you all truly believe that, if Republicans do take control of the Senate, there will be even more effort to repeal the Affordable Care Act?
DENTZERWell, certainly, we expect the votes to do so, to continue. There would be no reason to expect otherwise. Of course, as long as President Obama's in office, he's not likely to sign any of that legislation. I think the real question is: Will there be any meaningful effort to fix what are now widely perceived as some flaws in the law?
DENTZERWell, for example, there's something known as the family glitch, which is the way that, in effect, subsidies are calculated based on whether anybody in the family has coverage through an employer. It's a complicated situation, but essentially it forces some people to get less in the way of financial assistance than they might want if they wanted -- if somebody in the family is employed, but somebody else in the family wants to get coverage through an exchange, that needs to be fixed.
DENTZERI think there's concern about the employer mandate and setting basically part-time hours at 30 and having to cover people above that as a -- for an employer and whether that's had the unintended consequence of pushing a lot of people down in terms of their hours.
DENTZERAnd should we -- in effect, there's already legislation that's been introduced to raise the number of hours and raise that cut-off. So there are lots of these things that really would probably represent improvements in the law. The question is: Is there the political environment to pass something that is short of the repeal but nonetheless addresses some of these problems?
EILPERINAnd it's worth noting that, for example, there are a number of centrist Democrats who have introduced bills to address these problems. But even they privately acknowledge that there's almost no chance that they would be voted on before the November elections. So even though there is absolutely kind of a more of a policy consensus on what some of the legislative relief could look like, there's not the political consensus to make it a reality.
CAREYIf Republicans win the midterm, what will happen is we've seen all these repeal votes in the House die in the Senate. Well, if Republicans take the Senate, they'll bring them to the floor now. As Susan mentioned, the president's not going to sign them. There's likely not to be a veto override majority in either chamber. But it keeps up that drum beat for the 2016 presidential where there doesn't seem, as Susan -- or there doesn't seem to be the bipartisan consensus to fix problems with the bill because you'll have a presidential election coming up in 2016.
REHMMary Agnes Carey, she's senior correspondent for Kaiser Health News. Short break here. Your calls when we come back.
REHMAnd welcome back. You all know that the deadline for signing up for the Affordable Care Act was at midnight last night. However, there will be extensions for those who, on the honor system, tried to sign up and were either turned away or frustrated or glitched or what have you. Here's our first email, and I'd like to know if this is actually true. It says, "Why did Obamacare drive up prices for those of us who get employer-based insurance? We're not eligible to get Obamacare." Susan Dentzer.
DENTZERWell, part of the law created a so-called essential benefits package, which is a series of benefits that have to be in all health insurance now sold in the United States. And those contain some provisions that were not always a feature of employer-provided plans, for example, a ban on annual limits. A lot of policies said, we'll only pay out so much every year -- a ban on lifetime limits. Many, many policies had a lifetime cap of a million dollars. Well, if you have a serious disease or your child has, say, hemophilia, you will blow right past that cap early on in the child's life.
DENTZERSo doing away with some of those things necessarily costs money. It costs more. In theory, it provides much better protection for everybody. So that -- but, again, I have to say, in the great scheme of things, most of the analyses done show that this has had a modest effect on premiums, even for employer-provided premiums.
EILPERINYeah, I think one part of this shows you, of course, what happens often with people's political perspectives. For example, I talked to a small business owner in Ohio last week. And he was a critic of this before and is convinced that it's really affecting both his -- the premiums that he has to pay for his employees as well as whether he can get business from healthcare providers who are now having to deal with more requirements and things like that.
EILPERINSo certainly people who are predisposed to dislike this law are going to find these faults. And it really will take time to look through and kind of look at exactly what private insurance firms are reporting to Wall Street and others to get a sense of how it's playing out through the system.
REHMHere is a second email from a college student who's going to be graduating in May, says, "I have a job with full health insurance benefits waiting for me once I graduate." Lucky graduate. "What actions do I need to take? How does the Affordable Care Act affect me?" Mary Alice. (sic)
CAREYIf you've got an offer of insurance, take it. You're set.
CAREYYou don't have to worry about the exchanges. You don't have to be on your parent's plan. I echo your congratulations to this young graduate. It sounds like you're all set.
REHMAbsolutely. All right. Let's open the phones, 800-433-8850, to Richard in Haverhill, Mass. You're on the air.
RICHARDThank you so much, Diane and panel. Yeah, you know, this is going to be the Republican's signature issue, Obamacare or the Affordable Care Act. And the problem with the Democrats, they always lose the message, and they put themselves always on the defense. For instance, Republicans constantly repeat things over and over and over and over, the same thing, and -- you know.
RICHARDAnd the Democrats, they don't answer back. And, you know, there's so many positive things about the Affordable Care Act. Number one, 45,000 people die every year because they don't have healthcare. They don't have primary care to keep themselves healthy. And they've got to keep talking about the positive things about the Affordable Care Act. For instance, you know, the -- your child can be on your parents' insurance.
RICHARDAnd what's the other one, the big -- well, the, you know, pre-existing conditions that (unintelligible).
RICHARDPeople went bankrupt. A lot of people went bankrupt when they had these really health (unintelligible)...
REHMAll right. Richard, thank you. Did the Democrats blow it here? Did they not talk loudly and frequently enough about the benefits of the Affordable Care Act, Mary Agnes?
CAREYI think it's a combination of issues that Democrats -- the messaging has kind of been blown since the beginning. They also had a problem when the exchange wasn't working. It's really hard to get out there and talk about getting people enrolled in a program when your website isn't working. That's been a problem.
CAREYThe variance in the public opinion polls where the favorables just -- or the disfavorables, if you will, for the health law, a lot of people disliking it, disliking the mandate, made a lot of Democrats nervous. They're kind of back and forth about, if the public doesn't really support this, where do we go? Is this a winning issue or not for us? I think some Democrats now looking at the surge in enrollment and so on are taking a deep breath and thinking, as your caller's saying, we have a lot to talk about here. We really ought to push that going to midterms.
REHMAnd the polls are changing, Juliet.
EILPERINRight. What's really interesting, The Washington Post just had a poll that came out yesterday. And what's fascinating about that is support among Democrats has risen 11 points in recent months because of, you know, what we've seen in terms of just the progress on the website and enrollment so that roughly three-quarters of Democrats now support the law.
EILPERINBut it's one in five for the Republicans. And I think what's interesting to understand about this is who has the passion and who comes out in a midterm election because that's, in many ways, going to be a referendum on this law with real policy implications.
DENTZERIt's always been striking, since the law was enacted, if you look in the polls and ask people about individual components of the Affordable Care Act, without saying that they were part of the Affordable Care Act, you get 80, 90 percent approval doing away with pre-existing conditions, doing away with lifetime limits. So there's been a longstanding disconnect between what people understand about the law and what is actually in the law.
DENTZERAnd maybe finally some of that ground is being broached. I guess I would also say, if these numbers are right, if we do have 7 million sign-ups and some very large number of people in Medicaid, we could be on track to have signed up as many as 15 million people in the first year.
DENTZERThat's going to change the dialogue. That's about half of what the Congressional Budget Office said would ultimately be total enrollment under the Affordable Care Act.
REHMInteresting. All right. To Valerie in Houston, Texas. Hi there. You're on the air.
VALERIEI am 25 right now, and I am currently under my father's plan. And so I did not enroll in the Affordable Care Act. But I will be turning 26 in June, which is just a few months away, and I didn't want to have to sign up for something that I didn't really need to pay for. I'm in grad school. I have limited means. I just want to make sure I will still be OK when June comes around, and I will then sign up for health insurance.
CAREYShe turns 26 in June.
CAREYThat'll be a qualifying life event, one of these exceptions we've been talking about. And so she'll be able then to look at the exchanges. Does she qualify for a subsidy and so on? She can't be under her parents' plan anymore once she hits 26. It's OK though if she ways until June to enroll.
EILPERINAnd one of the things I think is interesting is you're seeing a lot of young people who are now eligible for Medicaid because they're not earning a lot of money. And so really the face of Medicaid is changing, and that's something that's certainly -- when this young woman goes to healthcare.gov or to her state exchange, she'll see whether that's a possibility for her.
REHMAll right. Let's go to the other spectrum and to Mary in Greenwood, Ind. Hi there.
MARYHi. Thank you for taking my call. I love the show.
REHMSurely. Thank you.
MARYI'm 80 years old. I live in Indiana. I was on -- I am on Social Security. And I was on Medicare, and I was drawing 900 and -- well, it was $976 a month. But they had taken out of that the cost of my Medicare A and B. And I was also paying $196 a month for a Medigap policy. And I just couldn't make it. So I applied for food stamps. At that time, Indiana gave me first 17, then 16, then $15 a month in food stamps because they say I make too much money. They expect me to live on $710 a month instead of $976.
MARYBut what they did was, in February, I got my check, and it was for $991 a month. But there was no deduction for Medicare and Medicaid. And they had sent me a letter saying that this whole thing is changing because of the Affordable Care Act and we'll send you a letter telling you where you stand. And I did not receive the letter. I still have not received the letter. And now the time is past to sign up for the Affordable Care Act. I don't know whether I'm covered or not since there was no deduction in my last check for Medicare.
CAREYThis sounds like a very complex situation.
CAREYFirst thing we should say, if you're on Medicare, you stay on Medicare. You don't have to worry about the exchanges and enrollment and so on, for example. OK. So whether this is a situation where we've had new bids by the insurer -- we just had a Medicare enrollment period. I don't understand if she's on traditional Medicare or if she's in something called Medicare Advantage which could impact that premium deduction.
REHMWell, what about Indiana itself? Did it go its own way, or is it involved?
CAREYIt wouldn't matter because she's on Medicare, and Medicare stay intact.
REHMI see. So she's OK.
CAREYShe's -- it sounds like some kind of a snafu that has nothing to do with the Affordable Care Act.
REHMOK. Well, let's hope for the best, Mary. Continue to pursue and find out what's going on for your own peace of mind. Let's go to Jason in Baltimore, Md. Hi there.
JASONHi, Diane. Thank you for taking my call. I appreciate.
JASONMy situation is kind of interesting. I am somebody who has benefitted from the Affordable Care Act to a point. I have a son with a disability who I no longer have to worry about the, like, pre-existing condition or lifetime limits. But at the same time, I'm also a person who has personally felt the increase of policy premiums. My employee-purchased healthcare has doubled to a point where I was basically priced out of my own plan to a much lower quality plan with a much higher deductible.
JASONThis becomes an issue now because things that were covered before, like my child's orthotics, are something that I have to pay out of pocket for primarily until the deductible is met. What is -- what can be done for my situation? I don't qualify for the exchanges. I don't, you know, qualify for any subsidies, but this is harming me financially in (unintelligible) my child.
REHMYeah, I understand. Susan.
DENTZERWell, I think what we are about to be refocused on again, as well we should be, is the extremely high cost of healthcare in the United States and how that is driving, and has driven, an enormous rise in health insurance premiums. Keep in mind, straight through the 2000s, health insurance premiums were rising 8, 10, 12, 15 percent a year.
DENTZERAlmost all household income increases over that period got eaten up by people's rising contributions for health insurance. So -- and we're not out of that dynamic. We've seen, for the last several years, a temporary slowdown -- we think temporary slowdown in the rate of growth of health spending in this country. But nobody believes that that's permanent. And now we really have to look ourselves in the eye and say, do we want to have the most expensive system in the world with the highest prices paid in healthcare anyplace in the world? Or are we going to do something about it?
REHMFormer President Jimmy Carter was on this program last week. He said he would prefer we all go into a Medicare system. Mary Agnes.
CAREYOne issue too about the Affordable Care Act, which we'll begin looking at even more as more data comes in, is the affordability of the premiums. Some of these policies have very high co-pays and deductibles. It depends on which medal level you pick. Some people may be in for quite a shock when they find out, let's say you have one of these catastrophic plans that are open to people under 30 and some other special exceptions. You could have $6400 out of your pocket before coverage kicks in.
REHMAnd you're listening to "The Diane Rehm Show." That sounds awfully expensive. Let's go to Ray in St. Petersburg, Fla. Hi there. You're on the air.
RAYHi, Diane. This is Ray, and thanks for getting my call. I've had an experience where I am self-employed for a long time. And I've been paying Blue Cross Blue Shield at least close to $600 a month on my, you know...
REHMRay, please turn down your radio. I think it's sort of feeding back to you.
RAYYeah, so I basically kind of waited for a little while to get the Affordable Healthcare Act only because, you know, I was trying to figure out how I could get insurance.
RAYBut yesterday I went through the system. I had a little bit of problem at the beginning to get in. I was able to call somebody to help me in the process. And from what I was paying before, that was almost $500 to paying $88 a month, it has really saved me a lot of money.
REHMHow typical is that?
DENTZERIt's not atypical. About 80 percent of the people who have signed up for coverage through the exchanges have been eligible for premium tax credits. And some portion of those have also been eligible for a separate set of cost sharing assistance. So for a number of people, you know, think about the average tax credit being $5,000. If you're spending $7,200 a year for insurance and you're getting a tax credit of $5,000, that's a substantial savings.
EILPERINAnd so what certainly President Obama, his aides, and other Democrats are hoping is people, like Ray, I believe, is doing, that he be telling his friends about this. So even if they're not in the system, if those people talk about this enough and share this and can convince people that they have a stake in this law, that's something that certainly can serve as protection against the Republican attacks, both in the election and also legislatively.
REHMAnd now we'll hear from Martin in San Francisco. Hi there.
MARTINHi, Diane. I'm absolutely loving the show, and I've got to tell you I'm one of those people that for years that did not have health coverage. Now, through the Affordable Healthcare Act, I have coverage. And it's a godsend. And, like you were saying, I've been trying to tell as many people as I can to go through this system because, I mean, healthcare -- I'm diabetic.
MARTINAnd to be able to get my medication and to be able to see the doctor and -- I mean, I don't know what to say to folks other than, you know, take your time, go through the process. Yes, it can be a little frustrating, but, you know, at the end of it, it's just wonderful.
REHMIt's worth it.
EILPERINAnd although I do think that your caller raises another point, which is now we're going to see people who haven't had doctor's appointments for a long time go and make these appointments -- and, of course, that's something that everyone would want. But also this is going to put pressure on the existing healthcare system that we have. So those are other issues that are raised by this act.
REHMAnd wasn't there something to the effect that the amount reimbursed to doctors through Medicare may indeed go down?
CAREYThey just passed -- the Senate last night just passed a one-year patch to this formula. We just call it the SGR, the Sustainable Growth Rate, to prevent that cut in Medicare physician payment. That's a separate issue. There are bills to overhaul the way Medicare pays doctors. But, for now, they'll be kept whole. But the larger issue of shifting Medicare away from paying for the quantity of services versus the quality, that's still out there -- part of that bigger discussion Susan's referencing.
REHMMary Agnes Carey of Kaiser Health News, Susan Dentzer of the Robert Wood Johnson Foundation, on-air analyst on health issues for the "PBS NewsHour," and Juliet Eilperin of The Washington Post, they'll all be here to answer your questions after a short break. Stay with us.
REHMAnd as we talk about the Affordable Healthcare law, we have several emails similar to this one from Noah in Norman, Okla. He says, "I'm wondering if someone who's leaving his current employer to become self-employed will be eligible for a special enrollment period." You're all nodding your heads. Juliet?
EILPERINRight. That is a life-status change, and so, as a result, you know, he will be able to change it. It also just speaks to the fact -- and Anthony Wright, a health expert out in California, was making this point to me recently. This is a fluid market. People are going to go in and out. So while we'll get one read on what the mix looks like, you have to just keep in mind that there will be changes throughout the year.
REHMAnd many people are confused about what happens after this enrollment period. Here's another email. She says, "My husband was laid off last year. We have healthcare until August of this year through his company. Will we be able to get insurance when that coverage runs out? Or will we have to wait until the next time the option opens?"
DENTZEROnce again, that person has a change in life status, would be eligible for the special enrollment period. There's lots of information about this on the HHS website. We expect that there will be more going forward. Probably a good idea to connect with an enrollment counselor now.
DENTZERJust -- but, absolutely, that is exactly the -- that kind of change in status is exactly what these special enrollment periods are intended to capture.
REHMOK. So tell me what's going on now. Now that the enrollment period ended at midnight last night, are people still answering phones? Is everything still continuing, Mary Agnes?
CAREYPeople who got in the virtual queue, if you will -- maybe they couldn't complete their application -- they'll get an email or a phone call telling them when to return. I'm sure that you've got caseworkers working through this backlog not only at the federal level but at the state level. Some states have given people more time to enroll in the program. Some states have not. So I think that they're still working through what seems to be quite a backlog.
REHMAnd how long is that going to continue, likely?
EILPERINWell, it's a little unclear. I mean, in terms of the honor system that we've referenced, if you want to do a paper application, they need to receive it by April 7, but the button will be up there online for longer than that. Some people who have called the call center, they're going to receive a call within the next five to seven days.
REHMOK. Here is an email from Ernie in Seattle: "Seven million enrollees is a big number but not compared to the 40 or 50 million Americans who lacked health insurance at the time the ACA was passed. What is the plan for enrolling the rest? What's the timeframe? When the dust has settled in a couple of years, how many people will still lack health insurance?" Susan?
DENTZERWell, that, of course, is the big question. It's important to note that that 50 million figure also includes about 10 million undocumented people. Those people were never going to get coverage under the Affordable Care Act. They were left out of the law completely. So unless we have some immigration reform…
DENTZER…that puts those folks on the path to coverage -- so that takes us down to about 40 million. As we've said, 7 million represents the people who apparently bought coverage through the exchanges. We have apparently 9 million people who are eligible for the Medicaid expansion. And that's even given the fact that only 26 states now have expanded their Medicaid program.
DENTZERSo we're going to have some pool of people uninsured because states did not expand Medicaid, because some people will be exempted for various reasons, and because some people will elect not to get coverage and pay the penalty. We just don't know what that number is going to add up to at this point.
REHMWhich states that did set up exchanges have done really, really well?
CAREYCalifornia has done really well. New York has done really well. Connecticut has done really well. In part…
CAREYKentucky, right. And in part it's because their electronic systems worked. They didn't have the problems that Oregon or Minnesota have had with their computer system to sign people up. That's really been critical because early entrants, they came in, and the system didn't work. They may not have come back. So that's been a hindrance for some states. It's been better for others.
REHMAnd in Texas, political opposition to President Obama's health law's so strong that maybe people thought it was banned in that state.
EILPERINRight. Although one thing that's really interesting there -- and that's, again, also a state there was not Medicaid expansion. The governor's very against this law, Gov. Perry. But what's fascinating is that you had advocacy groups, whether you're talking about the Service Employees International Union, Planned Parenthood, Enroll America, they really did what I call flooding the zone. They put a lot of organizers there. And so they were able to make some inroads, even though you didn't have support on the state level.
DENTZERAnd in Texas alone, almost 3 million people were uninsured and eligible for premium tax credits. So they would have had assistance to buy coverage.
REHMYeah. So now you've got some states changing their minds about Medicare coverage. You just had New Hampshire voting on Tuesday to do that.
REHMAnd now you've got 26 states, plus D.C., that have opted for expansion. So what happens in those states that did not opt in for Medicaid? Are Republicans going to pay a price here?
EILPERINWell, one of the great places to look at that is Pennsylvania, where Tom Corbett, the current governor has a tough race to begin with. He's unpopular for lots of reasons. And Democrats are using this as one of their primary arguments against him in the fall. So that's really going to be ground zero. Kind of similar debates are going on in Maine. And then you have something like Virginia, where Terry McAuliffe, who was just elected in the fall, he's pushing for an expansion. He's gotten pushback from the Republicans.
EILPERINAnd it's a huge issue and an impediment to a budget deal there.
REHMAll right. Let's go to -- let's see, Matthew in Clayton, N.C. Hi. You're on the air.
MATTHEWHi, Diane. Thanks for taking my call.
MATTHEWI'm 27. I teach at a couple different colleges as an adjunct. So I don't make a lot of money. And I'm not offered healthcare through my employer. I had Blue Cross Blue Shield Insurance, and just the other day I signed up through healthcare.gov. And for the same price, I actually still have Blue Cross Blue Shield Insurance policy, and I also have dental care. And my deductible isn't insane anymore.
MATTHEWAnd I'm telling a lot of my friends about it, and I'm sort of seeing it as like I'm a, you know, sort of a success story of this. I have much better insurance now. And I think that, you know, with a lot of my friends about my age, they were all really surprised. And they were like, you know, I can't believe you're getting better healthcare. I feel like a lot of times they think that immediately it's going to be worse healthcare. But, like, I still -- it's still Blue Cross Blue Shield for me. It's not like it's a, you know, government...
REHMSure, sure. Mary Agnes?
CAREYFor millions of people who are buying their health insurance in the individual market, they're some -- they're among the people who are going to see the greatest impact from the health law because you now have more formalized exchanges. You can't be discriminated against based on a pre-existing condition.
CAREYThe ability to age-rate for older folks -- some states had charged as many as -- an older person five times more than a younger person. Those limits have been scaled back. So this is part of the group. I think it's around 12 to 13 million people who buy in the individual market. They seem to be the most pleased -- not always. I mean, if they don't qualify for a tax credit, then you're not too happy.
CAREYBut if you qualify for a credit for the subsidy, your co-pay or deductible -- this can be life-changing for you.
REHMAll right. To John in Ann Arbor, Mich. Hi there. You're on the air.
JOHNDiane, thank you so much for taking my comment.
JOHNIt's about 70 seconds, if that's all right.
JOHNThe core deficiency of the Affordable Care Act is that it ignores the nub of the problem with our healthcare delivery system, our inordinate reliance on insurance and third-party payments. Such reliance in turn leads to soft-budget constraints which engender ballooning costs requiring administrative rationing.
REHMAll right. Juliet?
EILPERINIt's actually a very valid point there, folks. There's a whole book called "Catastrophic Care" that makes this point. And I think what's interesting about it is that the Democrats had a choice. They could have obviously done nationalized healthcare. They decided not to do it and had the insurance firms as allies. But there's no question that, as a result, it's harder to know what costs you're paying, and you have this middle man. And that obviously contributes to cost increases.
CAREYWell, although, as we have also pointed out, the deductibles on these plans are very high. Twenty-five hundred dollars is the average deductible for the silver plans. That's a lot of cost exposure for consumers. And we're already seeing a growing demand for transparency around healthcare pricing.
CAREYWe've had campaigns like Choosing Wisely to try to educate people about the things they should not ask their doctors to do and their doctors should not do for them. So we're evolving slowly to a point where people are, I think, doing a better job of shopping around for healthcare and mitigating some of the issues raised by third-party payment.
REHMIsn't someone trying to introduce a so-called Copper Plan?
CAREYYes, indeed. A group of five Democrats and one independent, Angus King of Maine, in one of the bills that has been proposed to amend that law, want to do precisely that, create an even cheaper plan called the so-called Copper Plan, even less comprehensive than the Bronze Plan, which is -- also has high deductibles and relatively lower premiums.
REHMAll right. Let's go to Lorraine in Tampa, Fla. Hi. You're on the air.
LORRAINEHi. Good morning, Diane.
LORRAINEI have a friend who signed up for the Affordable Healthcare Act at the end of last year, and he's very frustrated. I don't know all the details. But I know, whenever I talk to him, he's very frustrated because he can't find a doctor who will accept the plan. He's found -- he must have called -- he's looking for a primary care doctor. He must have called about five to seven doctors. And only two -- and one is a specialist, so he can't be his primary care -- have said that they will accept the plan.
EILPERINThis is -- I was going to -- it's a great point. The fact is that people are going to have to see how these plans work for them. And if they're dissatisfied, they're not going to be allies of the administration. So, for example, there's already an issue about provider networks in this country. And then, again, I also think what her friend's -- Lorraine's friend's situation speaks to is it's hard to get a general physician anyway. And so if you…
REHMBut that's because there's a shortage there.
EILPERINYeah, there's a shortage of primary care physicians. And you're not going to be able to introduce those folks to the system overnight, although maybe this gives an incentive for, you know, this in the future.
CAREYJuliet touched on this as the issue of narrow networks. It started before the Affordable Healthcare Act. It's part of the exchanges in some cases now. If you pick a plan, perhaps a Bronze Plan, you may get fewer choices of providers. You're going to hear about this. But this is an ability to drive volume to providers, in some cases, for the insurance companies to cut a bigger discount, so you, as the beneficiary, pay less. But this could -- you know, this is one of these emerging issues.
DENTZERAnd the administration has signaled that it is going to look very aggressively in the coming year at network adequacy standards and whether these networks really are broad enough and, importantly, whether they have so-called essential community providers as part of them. I would just say another very interesting development that, as people now are looking for alternate sources besides the conventional physician's office -- so your friend might want to look at community health centers as a potential place to go to get very good primary care.
REHMBut it does seem to me there's got to be some incentive for young people going to medical school to go into those areas that are shortaged right now.
EILPERINAbsolutely. You need a financial incentive because there's specialty practices that pay more.
EILPERINAnd so that's a challenge.
REHMAnd you're listening to "The Diane Rehm Show." Here's a tweet from Jonathan. He says, "My family is in between making too much for Medicare but not enough to get decent coverage through the ACA. It's cheaper to opt out."
DENTZERI would really examine that decision because of the penalty. Now, he says it's his family, right? So you're talking about, for an individual, it's 1 percent of income. And so a family, it's going to be -- or $95 a family, that's going to be higher. And then you're going to be on the hook for the bill. This is this problem.
DENTZERAnd as we experience our lives, you have unanticipated events. You get incredibly sick. You get hit by a car. You blow your knee out on the basketball court. You're going to get treated in the emergency room, but you're also going to get a bill. So that may not be cheaper for you to opt out if you have -- most of these things in our lives are unanticipated emergencies.
REHMAll right. And finally to Donna in Tallahassee, Fla. Hi. You're on the air.
DONNAGood morning. I just want to say, as a self-employed psychologist, my premium, once I turned 60, was $1,200 a month, which approaches 100 percent of my income. And so I was thrilled with the ACA. Now it's $107.24.
DONNAHere in our -- yeah. Here in our market, we have 27 choices to pick from. They're all Blue Cross Blue Shield. And you mentioned about the provider network system. I can't seem to find out that Blue Cross is opening their provider panel to any mental health practitioners.
DENTZERWell, it's Blue Cross. So it's unlikely that there are no mental health practitioners in a Blue Cross plan. Those tend to be more generous plans. Unfortunately, right now, we're at a point where, unless you are in contact with the insurance company, you may not know what providers are in the plan. Over time, the exchanges hope to have -- at least in many of the states -- plan to have very robust lists of what providers are in what plans. But, for the most part, we're not there yet.
REHMOK. And finally an email from IMED -- you all know that site? OK -- saying, "Employers are able to take advantage of the employee's lack of understanding and knowledge to change insurance plans and push costs on employees while blaming the ACA due to political uncertainty and squabbling."
CAREYWe were just talking about that, that people seem to blame everything on the ACA when it comes to health insurance costs. But you've got to remember, employers have long had the ability to pass increases onto employees. Some require higher deductibles. Some require higher co-payments. This is a tool that's been out there for a long time.
REHMAnd, of course, we have the case that just went before the Supreme Court as to whether a corporation can impose its religious ethical beliefs on its employees and not provide the kind of care that the Affordable Care Act demands.
EILPERINThe law has a requirement for contraception coverage. And there are certainly a number of companies, including Hobby Lobby, who brought the case that's pending before the Supreme Court, saying that they feel like being forced to provide this, even through a third party, is a violation of their religious beliefs. So we're all waiting to see. By June, we'll have a decision. And that -- and part of what that shows is the fight over this law is not ending.
REHMJuliet Eilperin of The Washington Post, Mary Agnes Carey, senior correspondent for Kaiser Health News, Susan Dentzer of the Robert Wood Johnson Foundation, on-air analyst on health issues for the PBS News Hour, you all have done such a service. Thank you.
CAREYThank you, Diane.
REHMAnd thanks for listening, all. I'm Diane Rehm.
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