Health Care Exchanges

Demand clearly illustrates the desire for health coverage.

By Dr. Harpal S. Mangat

Dr. Harpal Mangat

WASHINGTON, DC: The Affordable Health Care Act was passed by Congress in 2010 and signed into law by the President. The law was challenged in the Supreme Court and upheld, allowing the states to opt out of the Medicaid expansion part of the law.

Currently 25 states and the District of Columbia have opted in to Medicaid under the Affordable Care Act and another six in limbo, the tumult in a handful of holdout states is increasing. The White House hopes unrest in states like Florida, New Hampshire, Nebraska, and Maine will help turn the fight decidedly in their favor. And there’s good reason to think that’s happening.

New Hampshire, a state that was noncommittal on Medicaid expansion, is now on the brink of expanding coverage to approximately 50,000 poor residents. In Virginia, Democratic Gov. Terry McAuliffe has been fighting for Medicaid expansion since he was elected in November (the Republican-led House is opposed). In Pennsylvania, Republican Gov. Tom Corbett had originally proposed a modified version of the program, that is under review by the federal government. Utah Gov. Gary Herbert is discussing Medicaid expansion with administration officials. The governor, who initially refrained from opting in, in January vowed to take action on Medicaid expansion..

Let’s look at the Affordable Care Act. The Affordable Care Act actually refers to two separate pieces of legislation — the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 that together expand Medicaid coverage to millions of low-income Americans and make numerous improvements to both Medicaid and the Children’s Health Insurance Program (CHIP) . It creates Health Care Exchanges designed to give the public access to the benefits enshrined in the law directly. The Health Care exchanges are online facilities where individuals and families can determine if their families are eligible for Medicaid, and children are eligible for CHIP.

Those who are not eligible for Medicaid, it helps determines how much tax credit they can use to buy commercial insurance. In simple terms it provides “Medicare” type health insurance to all and gives tax credits to those who qualify.

There has been a lot of press about how the exchanges have not been able to handle the volume of traffic. Irrespective of how it has been set up the demand clearly illustrates the desire for health coverage.

The exchanges primary roles are as follows:

•        Determine if you meet criteria including Permanent Resident status and Citizenship to benefit from the new programs.

•        Verify via the Internal Revenue Service your eligibility for a health care benefit.

•        Enroll those who qualify for the expansion of the Medicaid and Children’s Health Insurance Program (CHIP).

•        Collect information to determine what type of tax benefit can be given to you to purchase commercial insurance (please read previous blog for calculations the affordability of the Affordable Health Care Act).

Once all the above has been verified it gives you the option to use these credits against individual health insurance policies in the local market place. The maximum annual cost of a policy for those approaching 400 % of the poverty line will be 9.5 % of their annual income and only 2% for those just above the poverty line.

The Kaiser Family Foundation estimates that over 17 million people nationally will be eligible for tax credits in 2014.  The national and state totals are shown in Table 1.  Three states (Texas, California, and Florida) each have more than 1 million tax-credit-eligible residents, and another seven states have more than 500,000 tax-credit-eligible residents.  At the lower end, seven states have fewer than 50,000 tax-credit-eligible residents, with the District of Columbia (9,500) and Vermont (27,000) having the fewest.  The five states with the most tax-credit-eligible individuals account for about 40 percent of all such individuals nationally.

In April  2014 Small businesses will be able to buy health insurance for employees on their own market place called SHOP. (SmallbusinessHealthOptions

Currently the individual & family policies on the exchanges fulfill the criteria outlined in the law (see blog the affordability of the Affordable Health Care Act). They are categorized along the lines of the Olympics Bronze, Silver, Gold and Platinum. The plan category you choose affects the total amount you’ll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum).

This isn’t the same as coinsurance, in which you pay a specific percentage of the cost of a specific service (please refer to the blog Buying health insurance is like learning a language ). However care has to be taken in evaluating all the plans offered. On the Maryland health exchange many of these insurances have additional co-insurances that will considerably increase the out of pocket expenses unless you read the fine print on deductible and coinsurance.

I recommend applying for Medicaid, even if your state isn’t expanding coverage. Even if your state is not expanding Medicaid, you should apply for coverage to see if you qualify. Each state has existing coverage options that could work for you– particularly if you have children, are pregnant, or have a disability. You can apply today by contacting your state Medicaid office. You can also apply by filling out an application in the Marketplace online or by contacting the call center.

What is not hitting the headlines is how the Accountable Care Organizations are improving the quality of care and decreasing the cost of care. In our practice we attempt see patients within 2 days from being discharged from the hospital and use the new transition codes to enable us to afford time to treat and prevent re-admission. For those health professionals interested in finding out how we advise over 400 physicians in Maryland via sister Accountable Care Organizations they can contact me at my twitter address listed below.

The net result of these changes have been better coverage and the institution of annual physicals encompassing preventive measures that pick up disease earlier and prevent expensive progression of the disease. Already this has slowed the progressive spiraling cost of healthcare, if we can move down from 17.9% of our GDP being spent on healthcare to the next highest  competitor Holland at 12% we can re-invest $1 trillion into the  US economy. (See blog The Affordability of the Affordable Health Care Act.)

(Harpal S. Mangat, MD, is in Practice in Maryland. He is an Assistant Professor at Howard University College of Medicine and on the Board of Maryland Collaborative Care, an Accountable Care Organization. He submitted recommendations to his US senator that got incorporated into the 2010 Affordable Health  Care Act.   He has two issued US patents and three additional patents that have been filed.

He is a graduate of the Royal College of Surgeons Ireland, trained at Trinity College Dublin, Oxford University and London University in Family Practice and Ophthalmology. In the US he trained at University of South Florida and Mercy Hospital Philadelphia in Ophthalmology and Internal Medicine. He is the transport physician for difficult cases returning to United Arab Emirates. His interests include innovative new technologies, Diabetes, Sleep Apnea and Lyme disease as well as long distance air transport of seriously ill patients.

He sees patients at his offices in Clarksburg and Follow him on Twitter @DrHSMangat)

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