Explaining Health Care Exchanges

If health care exchanges have you confused, you're not alone. Guest host Celeste Headlee talks to health reporter Mary Agnes Carey about the next phase of the Affordable Care Act.

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CELESTE HEADLEE, HOST:

I'm Celeste Headlee and this is TELL ME MORE from NPR News. Michel Martin is away. Coming up, some people might try to solve America's high divorce rate with counseling, but one attorney says the whole system is wrong and maybe we should try leasing our marriages the way we do our cars. We'll talk more about that in just a few minutes. First, though, a major part of the Affordable Care Act goes into effect this fall. States will launch new online exchanges where you'll be able to shop for and buy health insurance. And if you're unemployed or uninsured, there could be some new opportunities to get covered. But there are also a lot of opportunities to be confused and have questions. So we've been asking for your questions, and we heard from hundreds of you over Facebook. Here to help us answer some of those questions, once again, Mary Agnes Carey, senior correspondent at Kaiser Health News. That's a nonprofit news service not affiliated with Kaiser Permanente. Welcome back.

MARY AGNES CAREY: Thank you.

HEADLEE: We're going to talk about the exchanges in just a minute, but let's go over the big news of today in healthcare at least. Another provision of the healthcare law has been delayed, this time it's the cap on consumer costs. What does this mean?

CAREY: The health law starting January 1 was supposed to put a cap on out-of-pocket expenses for individuals and for families. For individuals, it was around $6,300, and for families, around $12,700. Many insurance policies currently have out-of-pocket caps higher than that, which means you would pay more of that to get your coverage and...

HEADLEE: To meet your deductible or...

CAREY: ...To meet your deductibles and your co-pays and so on. And so what the administration has said - and they actually said this a few months ago - is that if - for some group health plans that have different administrators - perhaps one company administrates the drug coverage, another company administrates the healthcare provisions of your plan - if you need some extra time to get those computers to talk to each other, you have an additional year. So those new out-of-pocket caps won't go into effect until January 20 - January 1, rather, 2015, for those particular plans that have multiple administrators.

HEADLEE: That are trying to get through all the bureaucracy.

CAREY: Trying to get through all the bureaucracy. But of course, if you have a chronic disease, you've got multiple sclerosis, you've got any kind of serious cancer and you're paying a lot out-of-pocket already, you wanted those caps to start yesterday.

HEADLEE: Yeah, absolutely.

CAREY: So this will be problematic for some people.

HEADLEE: OK, so let's talk about these exchanges. Many people are hearing this word exchange and not knowing entirely what it means. So first of all, explain to us what these exchanges are and who they're aimed at.

CAREY: These are online marketplaces where, starting October 1, consumers can go - and small businesses - and shop for coverage. You can look at the different plans. You can find out if you are eligible for a subsidy with...

HEADLEE: Wait. Consumers who are uninsured right now, or any consumers?

CAREY: Well, here's the catch, right. It's healthcare, so it's got to be complicated. Anyone can buy from the exchange, but you can only get a subsidy if you meet certain requirements.

HEADLEE: I see.

CAREY: OK. So they're really geared to individuals who are buying insurance on their own right now in the individual market - very expensive - small businesses with 50 or fewer employees that are out there trying to buy coverage. The thought is that the online marketplace, the exchange, will bring in insurers to compete against one another to help drive down prices. Now, whether or not that'll be the case is of great debate, but that's the theory behind it.

HEADLEE: All right, we're going to be talking more about exchanges before that October 1 deadline comes. But we want to focus on folks who are uninsured or underemployed or unemployed right now. Our first listener question is from Rachel Brilskie (ph) in Charlotte, North Carolina. She asks this.

RACHEL BRILSKIE: I'm going to be leaving my job at the end of the month. I'm wondering if the Affordable Care Act was developed to assist people like me, and will there be options for me to get affordable health care while I am out of work?

HEADLEE: What's the answer for Rachel, there?

CAREY: Two dates she's got to think about. You can't start looking at the exchanges until October 1. Coverage doesn't begin 'til January 1. So when she goes to the...

HEADLEE: Of 2014.

CAREY: 2014. That's right. So when she goes to the exchanges, she might be able to find out, can she qualify for a subsidy to help her with her premiums, can she get any assistance with their out-of-pocket expenses, co-pays and deductibles and so on. But she's going to have a gap in coverage, and so there's two other things I'd like to advise her to look at because going without health insurance is not the greatest idea. She could use something called COBRA, which employers offer.

HEADLEE: Which we have another question about...

CAREY: OK.

HEADLEE: ...In just a moment.

CAREY: It's expensive, but you can look at COBRA. She might also be able to get some sort of catastrophic plan to hold her over until her exchange coverage starts.

HEADLEE: Catastrophic plan covering just major injuries...

CAREY: Exactly.

HEADLEE: ...Surgery.

CAREY: High out-of-pocket, high co-pays and deductibles. But if she goes the catastrophic route, please make sure she understands the terms of that policy. How long is she locked in for? Can she get out in January to go on the exchanges, for example?

HEADLEE: All right, since you mentioned COBRA, this next question comes from Valerie Bouvier (ph) of Concord, New Hampshire. She wrote in she also will be unemployed as of October 1. She's eligible to extend her work insurance through that option, COBRA. So here's her question.

VALERIE BOUVIER: I know I'm eligible to continue coverage through COBRA, but I'm wondering if insurance through the exchanges would be a cheaper alternative, and am I even eligible even though I can get insurance through COBRA?

HEADLEE: What's her answer?

CAREY: Yes, she is eligible on COBRA to still buy coverage and go into the exchanges. My guess is because the exchange offers a variety of coverage - platinum, gold, silver, bronze - she might be able to find a more affordable alternative because under COBRA, you pay the entire premium...

HEADLEE: Yeah.

CAREY: ...Many people split that with our employers, plus a 2 percent administrative fee. So my guess is she'll get more affordable options on the exchange.

HEADLEE: All right. Here's a parent - we have got lots of question from parents. They're very concerned about covering their kids. Glenness (ph) says her daughter works in the fitness industry. She and her friends are being told that their hours will be cut because their employers won't have to offer them health insurance if they're part-time. Is this anecdotal, or is there actually a larger problem going on here?

CAREY: Well, it depends who you talk to. It looks like there are definitely reports around the country. Individual businesses are talking about doing this. Some business groups are interviewing their members, who are saying we're going to reduce full-time hours - and we have to remember, in the health law, full-time is 30 hours a week, not 37-and-a-half or 40. It's 30. So you do have - on one hand, you have these isolated reports, which opponents of the law, rather, say is a sign of a big problem. On the other hand, you have the administration and those who favor the law that look at government statistics that have found there are fewer part-time people looking for full-time work now than when the health law was signed into law into 2010. So from my perspective, I think what you have to look at is - we talked earlier about a delay in the health law, one provision...

HEADLEE: Yeah.

CAREY: Another provision delayed is this employer mandate, a requirement that if you have 50 or more workers - full-time workers, starting January 1, now, 2015, you have to offer coverage or pay a fine. What will employers do then? Do they reduce hours, as they're doing to this young woman? Will they say, I'm not going to add over 50 employees, so I don't have to meet the mandate? Or will companies with 50 or more employees simply say, you know what, I'm not going to offer insurance, I'm going to put my workers into the exchange? How employers behave looking forward, I think, is what we have to watch.

HEADLEE: All right, Mary Agnes, we have a couple minutes left. I want to get this last question in from a mom named Catherine (ph). She writes that her 26-year-old son works an hourly-wage job. His hours are low. He doesn't get health insurance, but he has a pre-existing autoimmune disorder. So what options does he have, either through these exchanges or elsewhere?

CAREY: If she looks at the exchanges, she should be able to find out, does he qualify for a subsidy with a premium for his co-pays or deductibles, his out-of-pockets? I'm also curious of whether, since he's a low - doesn't get a lot of hours and doesn't sound like he makes a lot of money, could he qualify for the Medicaid expansion? The health law - now, it did make this optional for states, but if he's in a state that expanded the Medicaid program - will expand it, rather, starting January 1 - he can make up to about $16,000 and qualify for Medicaid coverage. And if he's in a state that didn't expend Medicaid, if he's between a hundred and 400 percent of the poverty level, he might be able to get those subsidies. So I think she has a lot of options she could at least consider.

HEADLEE: And her - his pre-existing condition won't matter.

CAREY: Won't matter because starting January 1, they've got to be covered for adults. They're already covered for kids, but January 1, it's covered for the rest of us.

HEADLEE: OK, before we go, where do people go to get more information that they can understand about these insurance exchanges?

CAREY: There's several places you can go to find out if your state has an exchange. You could call your insurance commissioner's office. You could simply go to Google, type in the name of your state, type in, ACA health insurance exchange. You could also go to healthcare.gov, with the official government site. I'd like to plug Kaiser Health News - Kaiserhealthnews.org. We have a lot of information as does the Kaiser Family Foundation - www.kff.org.

HEADLEE: Mary Agnes Carey, senior correspondent at Kaiser Health News. That is a nonprofit, not affiliated with Kaiser Permanente. She was with us here in our Washington, D.C. studio. Thank you so much, as always.

CAREY: Thank you.

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