Bronze vs. Silver: What Factors Should Be Considered?

By Nicole Cardona

On October 1^st, 2013, hundreds of thousands of uninsured New Yorkers will have a choice: purchase a health plan through the New York Health Benefits Exchange (NYHBE), or remain uninsured and face a $95 tax penalty. Those who decide to purchase insurance—presumably those previously uninsured due to prohibitive premium costs—are most likely to consider the two plans with the lowest premiums, Bronze and Silver. The premiums for Bronze and Silver plans must cover 60% and 70% of medical services, respectively. New Yorkers must weigh the pros and cons of each plan as they try to incorporate premiums into their monthly expenses.

As a second-year college student in Boston, I am safely under the coverage of my school’s insurance—a plan whose full cost, despite existing in confusing columns of fees owed and aid received, I did not even have to pay. Though I have two more years before I must worry about obtaining health insurance elsewhere, I can’t help but think about how the Affordable Care Act (ACA) will affect me once I leave school. Provided “future me” is in good health, I would have been very tempted to join the ranks of the uninsured or purchase catastrophic insurance to avoid monthly premiums. However:

1) By 2016, the tax penalty for being uninsured will be $695—or 2.5% of income. For me and for most New Yorkers, this number is an enormous deterrent.

2) Having a strong family history of breast cancer, I am supposed to begin receiving screenings at the age of 25 or 26 (the same age, ironically, that I would be removed from a parent’s insurance, were I using it). While the ACA preventative care provisions include mammograms without co-pays, they only apply to women over 40, so I would have to pay out-of-pocket for such screenings, regardless.

Considering these two factors, it’s likely in my best interest to purchase a health plan when the time comes—probably Bronze coverage, as it will be more of a struggle to pay high monthly premiums than minimize out-of-pocket costs, but this may be my youthful sense of invincibility speaking. 

Yet, for somebody else—say, a non-smoking, 30-year-old single woman with no children, making $35,000 a year before taxes—choosing between Bronze and Silver coverage is a more difficult choice. The woman in this scenario could buy Bronze coverage and receive a $101 subsidy toward her $2,739 annual premium, paying $228 per month. Or, she could buy Silver coverage and receive the same $101 dollar subsidy towards a $3,426 premium, or $277 per month. With silver coverage, she’s responsible for 30% of her healthcare costs (as opposed to 40% with Bronze).

So what should she do? It depends on many factors—her monthly budget, her day-to-day health concerns, and how many specialists she may require, as the Bronze plan is expected to be the narrowest in terms of providers. Countless New Yorkers will have variants of this choice, and all the same factors should be considered. Because the costs for Bronze pricing were only recently publicized, not very much has been said about the level of coverage; therefore, people must know that flexibility is a priority the uninsured must take into account when choosing a plan.

TIME Talks American Healthcare

by Kayla Mahler

As BTTF Director of Communications, I’m always on the prowl for insightful healthcare news. At the store yesterday, I overheard a pharmacist and customer talking about the informative and powerful impact of Steven Brill’s TIME piece, “Bitter Pill: Why Medical Bills are Killing Us.” After reading it, I couldn’t agree more. Brill’s investigation of the state of American healthcare took over seven months of research.  I’ve recommended the piece to all my friends and colleagues (click on magazine below for access).

In the piece, Brill discusses the complex politics, economics and costs of routine care, medical technology, catastrophic illness, and much, much more. I’m particularly appreciative of Brill’s term “Insurance That Isn’t,” which refers to a major loophole in health insurance policies—when plans don’t fully cover routine or diagnostic procedures.  

Brill writes:

“Obamacare prohibited lifetime limits on any policies sold…and phases out all annual dollar limits by 2014…But Obamacare does little to attack the costs [that are…] the most surprising sinkhole—the seemingly routine blood, urine and laboratory tests.” 

Responding from the trenches, we at BTTF know this to be true: the demand from our community referral partners like Project Renewal Scan Van for our Diagnostic Program (which facilitates laboratory tests and diagnostic imaging for uninsured patients) increases drastically every year.  

Brill’s thought-provoking piece prompted me to write and share my own experience.  I have approximately one more year of insurance coverage (ending when I turn 26).   I’m very supportive of many Obamacare measures—I’ve even seen a few co-pays disappear.  That being said, I’m very nervous about having to purchase a plan for myself in 2014.  Based on estimated insurance costs, I can’t afford anything but a catastrophic plan (an estimated $125-$150 per month, a feasible amount for my budget).

The problem is, a catastrophic plan wouldn’t have covered me this year.  Within the past six months, I visited my primary physician at least three times.  Two visits were within the same week (for two different infections) and one visit was required before I traveled outside the country.  All three instances necessitated prescription drugs and several “non-preventative” laboratory tests. I feel all these visits and treatments were reasonable and ordinary for a healthy young adult. 

Yet, if I were enrolled in a catastrophic plan during these visits, I would have been responsible for paying for all the prescription drugs and tests, costing hundreds and hundreds of dollars, because they’re non-preventative. Unless my graduate school tuition disappeared, I couldn’t have afforded those bills.  I’m left wondering how  ”treating symptoms” translates to “non-preventative services,” and why such services should incur high out-of-pocket costs.  

While the New York City individual insurance market will see lower premiums in 2014, out-of-pocket costs for basic medical services remain too high.  Brill concludes, “Put simply, with Obamacare we’ve changed the rules related to who pays for what, but we haven’t done much to change the prices,” and from what I’ve experienced and seen, I agree. 

The ACA has increased the reach and capacity of our country’s healthcare system and has imposed new stakeholder accountability, but the issue of affordability remains.  Consumers must advocate for further changes in insurance policy and systematic healthcare reform.  

The Elephant in the Room: The Hidden Costs of Health Care

by Kalie Krueger

 What if your hotel bill was like your hospital bill? This video from the nonprofit Cost of Care provides a comical (but necessary) perspective on the inexplicable and shocking costs generated from minor hospital bills. What makes this possible, and how with the Affordable Care Act address this issue?

This New York Times article from late March reflects on two major contributions to the problem:

1. Range in Price for Goods and Services: In the USA, goods and services are primarily negotiated between individual health insurers and individual physicians, hospitals or drug companies, creating a system where costs for an identical service can be unpredictable and vastly different.
2. Opacity of Costs: Particularly for uninsured patients, complete cost information is extremely difficult to obtain.  In addition to closely guarding this information, private health care providers and other relevant websites are often hard to navigate; the price information written in a code that has meaning to health care providers, but is indecipherable to patients.

A report of Price Transparency in Health Care was conducted on March 18that gave New York and 28 other states a failing grade of F. While the Affordable Care Act has implemented steps for increased cost transparency and accountability, it is necessary for health care education to give this issue greater attention and importance before transparency can be met on both local and federal levels.

For uninsured patients, these hidden costs are not only hard to obtain ahead of time, but often are the cause of serious financial hardship or bankruptcy. Providing sufficient health care education for acquiring and comprehending costs of services is a vital step that must be taken to protect this demographic, as they have proven to suffer the greatest impact of costs but are the least informed. 

Health Care Reform and the Immediate Future: A Timeline

by Nicole Cardona

This article, published in last week’s New York Times, details the latest obstacles for President Obama’s health care plan: too much planning that remains unfinished, and not enough cooperation (or funding) coming from the Senate.

Here’s a basic timeline for what’s supposed to happen over the course of 2013-2014:

• April 2013: Insurers submit applications that describe the packages (benefits, costs, etc.) they wish to offer
• June 2013: Federal government establishes a telephone service to handle consumer concerns
• September 2013: Insurance programs are certified by state and federal government
• October 1, 2013: People begin to enroll in their chosen insurance programs
• January 1, 2014: Everyone (barring those with financial hardship exemption and those opting to pay the tax penalty) must have insurance
• March 31, 2014: Special enrollment period ends
  

It’s almost April. This means there are only six months left until enrollment begins. Throughout these six months, it’s important that several things take place. For the sake of the law’s success:

•  All states need to incorporate the new federal regulations into their own state law
• The government must figure out how they’re going to help thirty-three states set up and staff the exchanges

More importantly, for the sake of millions of Americans now facing these changes health care education must be improved at the federal and community level. An enormous number of people need to be made aware of what direct consequences they’ll face as a result of this reform. Unfortunately, the “uninsured” demographic (which will be among the most greatly impacted by the law) is also among the least informed.

A recent poll showed that 2/3 of uninsured Americans lacked the information to really understand the law’s implications (Kaiser Family Foundation). BTTF is helping educate New Yorkers on this matter, but we can’t do it alone! Contact kayla@the-bttf.org if you’re interested in getting involved with the BTTF health reform education program. 

BTTF Patient Lisa’s Story: Growing Up Under-Covered in NYC

Who Will Remain Uninsured in New York in 2014?

In the Empire Justice Center’s presentation, “The Affordable Care Act: Impact on NYS, Trilby de Jung offers the following statistics to the question, “Who Will Be Left Behind?”: 

• Undocumented immigrants (400,000)
• Eligible but unenrolled in public programs (up to 1M)
• Those qualifying for hardship exemptions (200,000)
• Those paying penalties (190,000)

These groups may leave a total of 1.4 to 1.8 million in NY uninsured.  It seems counterintuitive to leave nearly half a million people uninsured because they qualify for hardship exemption or pay the tax penalty—certainly, a large portion of these individuals and families want health care and are willing to pay for it, but just can’t afford the costs being proposed.   This especially affects those living in New York City, because the cost of living is so high. 

BTTF’s internal survey in 2011 indicated that low-income patients, earning $28,000-$50,000 annually, on average, could pay up to $1200 annually for coverage.  Of course $1,200 can’t provide the same full coverage, but wouldn’t the state prefer 400,000 people to pay this amount as opposed to nothing at all? There must be a compromise, somewhere.

Premiums: Pre and Post Reform

The Urban Institute published “ACA Implementation in New York,” which contains many useful projections specific to healthcare reform our state.  BTTF found the below chart particularly interesting:

This chart refers to average annual premiums in the “non-group” market, or, “non-employer” market.  This category is where many BTTF patients—freelancers, non-union workers, part-time employees, etc. fall into.  

Based on this chart, it seems like the biggest cost decrease occurs in the private insurance market.   Does that really help those currently without access to insurance? ACA exchange premiums for individuals are expected to range from $4,000-$6,000, which leaves us asking the same question: is insurance really that much more affordable for low-income groups who don’t qualify for Medicaid? As always, premiums don’t include out-of-pocket costs.

Defining “Dependent” in 2014

Happy new year!  BTTF has been very busy the past few weeks preparing healthcare reform materials for our patients and community partners—we’re very excited to share them with you over the next coming weeks and months.

Spreading the word about healthcare reform is especially important because official Navigator and In-Person Assistance Programs will not be implemented by New York State until July or August of 2013.

BTTF was very surprised to learn from Robert Pear’s article in the New York Times that:

“A dependent is an employee’s child under the age of 26…Dependent does not include the spouse of an employee…Thus, employers must offer coverage to children of an employee…[but] do not have to offer coverage at all to the spouse of an employee.”

Many of BTTF’s patients have shared their frustration about not being able to receive coverage through their spouse.  This issue is particularly challenging for any couple who either have or want to have children, and only one parent can work full-time.  

Does that mean that couples could potentially be forced to pay for two entirely different health insurance plans every year to avoid paying tax penalties? 

Uninsured in the Middle: Angela’s Story

Preventive Care Under ACA: What it Means and What it Costs…

How will The Affordable Care Act (ACA) change insurance coverage of preventive services, and what will this mean for breast cancer prevention and detection?

 Let’s start by defining preventive care:

• Preventive services can help individuals avoid or delay the onset of disease to live more healthy, productive lives.
• The word prevention usually brings to mind interventions that aim to prevent a person from developing an illness, as in an immunization like the flu shot.
• Prevention also includes services intended to diagnose and treat an illness at an early stage. Many diagnostic tests like mammograms therefore fall under the prevention umbrella.

In order to improve the accessibility and affordability of preventive care, the ACA requires all health insurance plans beginning on or after September 23, 2010 to cover recommended preventive services at absolutely no cost to patients (1).

Based on the U.S. Preventive Services Task Force, several breast cancer preventive services will be provided at no cost to patients (2):

• Well-women visit to determine appropriate preventive services
• Breast cancer screening (mammography)
• Counseling about BRCA screening
• Breast cancer chemoprevention medication

Missing from this list are many of the diagnostic services that are integral to providing early detection of breast cancer:

• Radiology & Imaging Services (Ultrasound, MRI)
• Diagnostic Laboratory Services (Fee for reading Biopsy results)

 The benchmark plan selected for the New York state-based health benefit exchange, Oxford EPO, does “cover” these services (3). But at what cost to the patient? Will patients purchasing plans from the exchange in 2014 be able to afford the associated co-pays or deductibles? 

 (1) http://www.healthcare.gov/news/factsheets/2010/07/preventive-care-background.html#_ftn1

(2) http://books.nap.edu/openbook.php?record_id=13181&page=34

(3)http://www.healthcarereform.ny.gov/health_insurance_exchange/docs/milliman_report_essential_health_benefit_options.pdf

Sneak Peak at the Virtual Insurance Marketplace

We tuned into the webinar tour of UX 2014, the prototype virtual marketplace that the New York State Health Exchange (NYSHE) will use as a blueprint for their own website where consumers can purchase health insurance. 

The interface is user-friendly, but doesn’t explain how you pay or more importantly, what you’re paying for.  We also found it strange that that consumers are asked to prioritize between high quality preventative care, caliber of doctors and hospitals, and customer service.  Shouldn’t we receive high quality care in all these areas?

We acknowledge UX 2014 is just a prototype, but based on similarities to the private insurance enrollment process, the actual NYSHE probably won’t be much different.  

These questions STILL remain:

• Where and when do you find out the maximum out-of-pocket costs you’re liable for? 
• How much will you pay for specific procedures? Our patients need to know how much common procedures like an MRI or biopsies will cost before purchasing.

 More to follow…

Mythbusters: The ACA Edition

If you’re like most of us, you’ve probably never read through the thousand-page Affordable Care Act.  Now that healthcare reform is here to stay, maybe you’re wondering, ‘what does it mean?’ This week we’re taking a look at three common myths surrounding the ACA.

Myth #1: Everyone will be covered under the Affordable Care Act.

Starting in 2014, most people will be required to have health insurance or pay a penalty.  There are some exceptions to the rule, including:

·               People who would have to pay more than 8% of their income for health insurance

·               People below the income tax filing threshold (2012 thresholds: $9,750 for singles under 65 years old and $19,500 for married couples both under 65 years old)

·               People who are uninsured for less than three months of the year

·               Undocumented immigrants, incarcerated persons, persons who qualify for religious exemptions, and some Indian tribes

Even with the exceptions, millions of Americans will still need to decide whether or not they purchase health insurance.  Those who choose to do without it will pay the higher of two amounts: a set percentage of their income or a fixed dollar amount.  The penalty also depends on the size of the household.  To find out how much you will pay, visit heathinsurance.org’s penalty calculator at http://www.healthinsurance.org/learn/obamacare-penalty-calculator/

Myth #2: All businesses will be required to provide health insurance for their employees.

            Large companies with at least 50 fulltime employees will be required to provide health insurance for their fulltime employees or pay a penalty.  On the other hand, smaller business, with less than 50 fulltime employees will not be required to provide healthcare for their employees.  

Myth #3: Americans will no longer face barriers to preventative care services.

            The ACA makes major strides to improve access to preventative care services, especially for women.  However, how much you pay for these services depend on many factors such as the plan you purchase, your age, gender, and health status.  For example, breast cancer mammogram screenings are only covered with no cost sharing for women over the age of 40.     

            While the ACA allows for many positive changes that make heath care more accessible for some, there are still holes to fill and more work that needs to be done.  We at the BTTF aim to help women stuck in those holes.  For a quick video tutorial on the basics of the Affordable Care Act, visit http://healthreform.kff.org/en/the-animation.aspx?source=FS.  

Uninsured in the Middle: Lana

Week Eight:

One day after the re-election of President Barack Obama, this patient scenario also concludes our Uninsured in the Middle series.  

Over the past eight weeks, BTTF has shared potential 2014 scenarios to draw attention to issues specifically affecting uninsured individuals and families earning $30,000-$50,000.  For these patients, BTTF remains concerned about high out-of-pocket and monthly costs, enrollment navigation and general compliance.  

With President Obama’s re-election, health and community organizations must now focus on how to best inform those they serve about health reform changes.  

Journalist Kelly Brooks reflects this challenge when she writes:

…Federal subsidies provided in the ACA will act as a major enticement for future enrollees. But explaining the subsidies and the four levels of coverage — bronze, silver, gold and platinum — will require effective and sustained educational campaigns…Navigating today’s fragmented health system is challenging for the most insurance-savvy among us. 

Despite the challenges ahead, we’d like to conclude our Uninsured in the Middle series by acknowledging  that healthcare reform will help millions of Americans, including Medicaid recipients and individuals living at 133%-200% of the Federal Poverty Level, such as Lana:

Lana benefits tremendously from health insurance provided by the Affordable Care Act. BTTF only wishes our patients could pay similar rates.

So what’s next for BTTF? Check back next Tuesday to find out!