Guest Host: Tom Gjelten

Three weeks from today, Americans without employer-sponsored health insurance will be able to buy insurance through state marketplaces. The idea for these exchanges, a key component of the Affordable Care Act, was to provide a way for uninsured people to obtain coverage and to enhance affordability for low income buyers through federal subsidies. Polls suggest there are many questions about how these exchanges will operate, and how the affordable care act will affect, if at all, employer-sponsored health benefit plans. Guest host Tom Gjelten and his guests discuss the state health insurance marketplaces and shifts in the overall health insurance market.


  • Julie Appleby Senior correspondent, Kaiser Health News.
  • Susan Dentzer Senior policy adviser, Robert Wood Johnson Foundation and on-air analyst on health issues, PBS NewsHour.
  • Ceci Connolly Managing director and leader of PwC's Health Research Institute; co-author of "Landmark: The Inside Story of America's New Health Care Law and What It Means for Us All."
  • Tim McKinney President and CEO, United Way, Tarrant County, Texas


  • 10:06:54

    MR. TOM GJELTENThanks for joining us. I'm Tom Gjelten of NPR sitting in for Diane Rehm. She's on vacation. State health insurance exchanges, a key provision of the Affordable Care Act, are scheduled to open for business Oct. 1. But would-be buyers on these exchanges say they need more information. Joining me to talk about the startup of health insurance exchanges and overall shifts in the health insurance industry: Julie Appleby of Kaiser of Health News, Susan Dentzer of the Robert Wood Johnson Foundation, and Ceci Connolly of PwC's Health Research Institute.

  • 10:07:53

    MR. TOM GJELTENI'm betting this will be one of those days when we get a lot of listener calls. Our number, remember, is 1-800-433-8850. Our email is And if you want to send us your comments on health insurance exchanges via Facebook or Twitter, you can do that as well. Good morning, everyone.

  • 10:08:14

    MS. JULIE APPLEBYGood morning, Tom.

  • 10:08:14

    MS. SUSAN DENTZERGood morning.

  • 10:08:14

    MS. CECI CONNOLLYGood morning.

  • 10:08:16

    GJELTENSo, Julie, the latest polling from your own organization, correct, shows a lot of people feeling they don't know what's going on with these insurance exchanges. Is that right?

  • 10:08:30

    APPLEBYWell, the Kaiser Family Foundation is -- they do a lot of polling. I work for Kaiser Health News...

  • 10:08:33


  • 10:08:33

    APPLEBY...which is an editorial independent program of the foundation. But, yes, they've done some polling, and they found that something like 42 percent of people really don't even know that the law is still in effect. So that's probably the first challenge for these insurance market places to just let people know, hey, they even exist. There's this health law. It's in effect. There's these new policies that are available. There are subsidies. So that's their first challenge starting right about now.

  • 10:09:00

    GJELTENI guess the problem is that this is such been a complicated law that I guess we can't really blame people for not really understanding it and sort of wanting to put off trying to figure it out.

  • 10:09:10

    APPLEBYYou know, it really is complicated. I've been covering this for four years, and I learn something new about it almost every day. So it is complicated.

  • 10:09:17

    GJELTENWell, Mary Beth, we're going to focus today on the health insurance exchanges. Give us the idea, you know, what is the idea of what they are supposed to do and how they're going to operate.

  • 10:09:29

    DENTZERSo I'm Susan Dentzer.

  • 10:09:31

    GJELTENI'm sorry.

  • 10:09:33

    GJELTENI'm so sorry, Susan.

  • 10:09:34

    DENTZERWell, quite all right.

  • 10:09:35

    GJELTENI'm so sorry.

  • 10:09:36

    DENTZERSo it just shows how confused we all are about all this stuff.

  • 10:09:38


  • 10:09:40

    DENTZERSo the exchanges are meant to serve a certain part of the population only, and that's another important thing to note here. Essentially, when everybody who's eligible for the exchanges is now fully signed up, it will only be about one out of 10 Americans. The exchanges or marketplaces, as they've been redubbed by the administration, are aimed at people who do not have health insurance currently or are buying it in the individual health insurance market.

  • 10:10:08

    DENTZERThey can't be getting coverage offered to them through employers that is affordable. So since the vast majority of Americans who do have health insurance are enrolled through coverage through their employers, they don't really have to worry about the marketplace. That's not for them. The marketplace, again, are meant for those who are buying coverage individually as individuals on the market and for employees of small businesses because the states are also operating so called shop exchanges. Those are small business exchanges for the employees of small businesses.

  • 10:10:40

    GJELTENAnd, Ceci, these exchanges can be run either by the federal government or the state governments, and the plan was that state governments would be doing it but not that many states are doing it as was thought to be the case, right?

  • 10:10:56

    CONNOLLYYes. The expectation was that this was going to really be state driven, and that we'd see a lot of experimentation and innovation out there. States are often referred to as the laboratories when it comes to public policies and partly because of politics and partly because of the complexities and the challenges involved in this. You have on the order of I think 17 states and the District of Columbia that are going to ahead on their own.

  • 10:11:25

    CONNOLLYThere's also the option which we're seeing in a number of states to kind of partner with the federal government kind of divide up the duties. We certainly expect that more states will take on more and more of the responsibility in the coming years as they kind of get these IT systems in place, and they see how the insurance is working out and that sort of thing.

  • 10:11:48

    CONNOLLYAnd, I think, for most consumers, that may not matter a whole lot. What's going to matter is how many health insurance companies are offering plans in their given state and what are the prices and products for the health plans they'll shop for.

  • 10:12:05

    GJELTENAnd, Julie, what's the -- Oct. 1 is when these exchanges are going to be up and running. Are -- the people who are going be doing this, are they ready for that starting date?

  • 10:12:16

    APPLEBYYou know, that is the big question, but they say they're ready. The federal government says they're going to be ready. The states are moving along. Now, we have heard from a couple of states. Oregon is one of them that said they're going to do kind of a soft launch. You're not going to be able to sign up immediately through their website. You're going to need to go to special navigator or broker, somebody to help you initially.

  • 10:12:36

    APPLEBYThey hope to work out all the bugs in the first few weeks, and eventually, the idea is you're going to be able to go online. You'll be able to check and see if you're eligible for subsidy. You'll find out how much that subsidy. You can pick a plan from among the choices that are offered and enroll right there. But, initially, it may not be online. And California, another big state that's doing its own exchanges, also indicated that it might have to do a similar sort of soft launch, although I don't think a final decision has been made on that yet.

  • 10:13:03

    DENTZERThe important point to underscore here is that this coverage takes effect in January. So people have all of October, November and December to sign up. And indeed, coverage, the open enrollment period goes through the end of March. So even if you wait to buy this coverage until the 31st of March, you're going to be OK, and you will still comply with the coverage requirements in the law.

  • 10:13:24

    GJELTENWell, Susan, will these -- some of these exchanges are actually physical locations where you can go in, in person. I mean Julie mentioned websites, but you can do it either online or in person at least in some cases, right?

  • 10:13:41

    DENTZERWell, it -- by and large, the exchanges are online sites. You can go and get help from people in various places to help you sign up online. We should underscore, too, that for the states that have elected to have the federal government run the exchanges for them, you will be signing up entirely online. You'll go to You'll fill in your state. Then you'll be directed toward the sub-site of the site that takes enrollment for your state.

  • 10:14:11

    DENTZERSo for that vast majority of people who are going to be eligible in those particular states, that's how they will sign up. As we've said, there's a whole manner of people out there to help you, navigators, assisters, various enrollment counselors, certified application counselors. You can find out about those on the site of an individual state exchange. Those will list frequently who those people are who can help you out and a whole other array organizations that have hospitals. Many physicians' offices are also helping people to sign up for coverage.

  • 10:14:48

    GJELTENCeci, do you have an idea of for those people who are right now uninsured, they probably don't have a lot of experience even like evaluating health insurance programs or people who work for employers with fewer than 50 employees, will these exchanges be sort of user-friendly enough that people will actually be able to make intelligent, informed decisions about what kind of health insurance makes sense for them?

  • 10:15:15

    CONNOLLYAnother excellent question, Tom. Certainly, the devil will be in the details. But I have a little more confidence in many of these state exchanges than I think some people. I think it might -- people had suggested, well, maybe it will be Amazon style or Expedia style. More recently, people are comparing it to, say, TurboTax when you go online and you plug in information to do your taxes, so some sort of a form.

  • 10:15:39

    CONNOLLYBut, you know, I remember back when Medicare added the Part D prescription drug benefit. And we were all so concerned that senior citizens were going to be overwhelmed, and they weren't going to know how to sign up. And in fact, those initial months and first year were pretty balky and challenging to say the least.

  • 10:15:59

    CONNOLLYAnd I think we should expect the same this time around. But I can tell you now, my mother is 75 years old. She hops on her laptop and plugs in her information, her ZIP code and her drugs, and she gets the plan that she wants every fall. And so I think we have to give consumers a little credit in this as well.

  • 10:16:16

    GJELTENMm hmm. And, Julie, I mean, let's -- what's the population category that you're most concerned about here? Is it those people who have never had insurance that don't have insurance now that are sort of suddenly confronted with a bureaucracy and some confusing situations?

  • 10:16:32

    APPLEBYYou know, I think frankly right now just purchasing insurance even right now is very confusing for most people. I've done a lot of stories about this, and folks go out there in the marketplace. They find that they can't get coverage. They find that it's more expensive than they thought. It varies in different states. A lot of that changes. Starting January 1st, they can no longer turn people down who have an illness, for example, like they can do now.

  • 10:16:51

    APPLEBYThere's some new rules. That said, it is still going to be complex. You're going to have to figure out what kind of plan do you want. They're separated into several categories. There's the bronze. There's the silver. There's the gold and the platinum, and they cover varying amounts. How much of a premium do you think you can afford? Will you qualify for a subsidy? So there's a number of choices that people are going to have to make.

  • 10:17:11

    APPLEBYSo it's not necessarily going to be -- it will be a little easier than today because there are going to be some standards. You can compare plans to plans a little bit easier than you can today, but it still may be challenging for some folks. And I think financially it may be most challenging for folks who are in the subsidy category at the upper end of the income. Remember, subsidies go from about 11,500 to $46,000 of your income. Folks who can qualify there in those upper ends, it might be a little bit more challenging for people to afford it.

  • 10:17:39

    GJELTENSusan Dentzer, what are the major choices that consumers are going to have to face as they look through these exchanges?

  • 10:17:45

    DENTZERWell, the number one choice that, as Julie said, is going to be cost. How much does it cost? What's the monthly premium? And there I think there's a lot of good news to offer to consumers. If you take the so-called silver plan, that's the plan that covers 70 percent of what's called actuarial cost. It means essentially what is your whole health care going to cost for a year and how much of it are you going to pay out of pocket versus the insurer?

  • 10:18:12

    DENTZERSeventy percent of those costs will be picked up in the silver plan. So it's a good, good plan for many, many people. If you look at the prices for those plans, they range as low as less than $200 a month for a 40-year-old nonsmoker in Maryland to $383 in Vermont. That's a lot more affordable than the coverage that has been on the market today. So cost is going to be key.

  • 10:18:36

    DENTZERAnother very important choice for people is who's in the network, what hospitals, what physicians, et cetera. And a lot of these lower cost plans have gotten that way because they've struck deals with hospitals and doctors to pay them a little bit less to make the coverage more affordable so that also will be important.

  • 10:18:54

    GJELTENSusan Dentzer is senior policy adviser at the Robert Wood Johnson Foundation. She's also an on-air analyst on health issues for the "PBS NewsHour." We're talking about the health insurance exchanges which are going to start, going to open their doors on the 1st of October. We're going to take a short break now. Please stay with us.

  • 10:20:24

    GJELTENAnd welcome back. I'm Tom Gjelten, sitting in today for Diane Rehm on this very important program where we're talking about health insurance exchanges. They're going to open for business on Oct. 1. My guests are Julie Appleby, who is senior correspondent for Kaiser Health News, Susan Dentzer, senior policy adviser at the Robert Wood Johnson Foundation, Ceci Connolly, managing director of PwC's Health Research Institute.

  • 10:20:48

    GJELTENAnd you can join us. Our lines are already full, but we can -- almost full, but we can take a few more calls. That number is 1-800-433-8850. And joining us now from Fort Worth, Texas is Tim McKinney. He's the president and CEO of United Way in Tarrant County, Texas. Tim, good morning. Thanks for joining us on this program.

  • 10:21:09

    MR. TIM MCKINNEYGood morning, Tom. Glad to be here.

  • 10:21:11

    GJELTENYeah. So we were talking earlier in the opening of this program about the role of navigators in helping people navigate their way through this very confusing bureaucracy and the regulations and so forth. I understand that you at United Way in Tarrant County, Texas applied and were awarded a grant to help get the word out about health -- the health exchange in Texas. Is that right?

  • 10:21:37

    MCKINNEYThat's right. We were awarded the largest such grant in the country, $5.8 million. And just very briefly, we were the lead organization of a 16-member consortium that covers about 220 counties of the 254 counties in Texas.

  • 10:21:54

    GJELTENAnd give us the sense, Tim, how you're going to spend that money and what the challenge you're facing there in your county is.

  • 10:22:01

    MCKINNEYWell, the challenge that we're facing obviously is to hire and train navigators and get them prepared and educated to help the consumer by Oct. 1. And we will use the money to hire about 75 navigators statewide.

  • 10:22:22

    GJELTENAnd who is -- who are your -- who's your target audience, uninsured people?

  • 10:22:28

    MCKINNEYUninsured people. Texas, as you probably know, has the greatest number of individuals uninsured in the country, about 4.8 million people. And of that number, about 2.2 million people will be eligible under the marketplace.

  • 10:22:45

    GJELTENAre you ready for Oct. 1? Do you feel like you -- have you got the -- have you been able to get the navigators on board to take on this challenge?

  • 10:22:54

    MCKINNEYWell, we're getting ready. We have hired navigators. We have not completely hired out the entire 75, but the navigators that we have hired have begun training. And we are pretty confident, very confident that we'll be ready to go Oct. 1.

  • 10:23:13

    GJELTENDo you -- Tim, do you have any questions yourself about how this process is going to work? Are there, you know, are there sort of unresolved things that you're waiting to see addressed?

  • 10:23:24

    MCKINNEYWell, the biggest unresolved is the products themselves. The Department of Texas Insurance has not announced what products will be available. It's our understanding that over 120 insurance companies have applied to, you know, have products available that we expect by the end of next week that the Texas Insurance Department will announce the products that are going to be available.

  • 10:23:53

    GJELTENGood enough. All right. Well, thank you so much, Tim. Thank you for joining us and filling us in on the situation there in your county.

  • 10:24:00

    MCKINNEYMy pleasure, Tom. Thank you.

  • 10:24:01

    GJELTENTim McKinney is president and CEO of United Way in Tarrant County, Texas. Ceci, let's talk about the problem of -- a little more about the problem of uninsured people. There are still going to be because a lot of the uninsured people might have gotten coverage through Medicaid if their states had agreed to take more money from the federal government to expand the Medicaid program. Texas is one of those states that didn't take that money.

  • 10:24:33

    GJELTENWhat's going to be the consequence for some of those poorest people in Texas who don't have health insurance right now and similarly situated people in other states?

  • 10:24:42

    CONNOLLYThat's a concerning issue, Tom. As you know, when the Supreme Court upheld the constitutionality of the Affordable Care Act and, at the same time, said that this Medicaid expansion up to 138 percent of the federal poverty level, which is about $15,800 for an individual, they said that states had the option on whether or not to do that. So as you point out, many so far are not going for it.

  • 10:25:09

    CONNOLLYAnd so we will have a gap in the safety net, an unintended hole in the safety net, which is very unfortunate. We do suspect that many of them will continue to do what they do today, which is typically show up at the emergency department. That's why -- it's one of the reasons why it's so important to get everyone covered so that you don't have that dynamic at work. But that will still occur.

  • 10:25:33

    CONNOLLYIn addition, it's important to point out that undocumented immigrants are not covered by this legislation. And there are probably also some number of individuals who will decide not to follow the law. There is now going to be a requirement starting Jan. 1 that every single one of us carry health insurance with some exceptions on income. But really, that's going to be a requirement. Some people will pass and probably pay the penalty, which in the first year is only $95.

  • 10:26:03

    GJELTENBut it gets more in other years, doesn't it?

  • 10:26:05

    CONNOLLYIt -- up to about $695 by 2016.

  • 10:26:10

    GJELTENSusan Dentzer, as Ceci said, this was an unintended development. To what extent does it undermine sort of the cost-cutting rationale of the whole Affordable Care Act to have so many people sort of outside its reach?

  • 10:26:24

    DENTZERIt does undermine that and also undermines the coverage rationale. We really had split up the population of people without coverage and said the poorest of those people will go into an expanded Medicaid program. The next -- better-income people will be able to buy coverage through the marketplaces.

  • 10:26:41

    DENTZERThe irony of the states' Medicaid decision, the states that have decided not to expand Medicaid is that the poorest adults will be left out of coverage. But near-poor adults who are better off will still be able to buy coverage through the marketplaces and get subsidies. So we've actually created a situation where the poorest people really are the most disadvantaged, and better-off poor people are less disadvantaged. It's really kind of nuts.

  • 10:27:08

    GJELTENI don't quite understand that, why the poorest people aren't in position to get the subsidies that people with a little more money get.

  • 10:27:14

    DENTZERIt's the way the law was written. The assumption was that everybody below, as Ceci said, 138 percent of the poverty level would be in an expanded Medicaid program.

  • 10:27:24


  • 10:27:25

    DENTZERAnd when the Supreme Court threw a ringer into all of these, the really -- that fundamental logic of the law collapsed.

  • 10:27:32

    GJELTENAnd, Julie, is this something that these states are going to have to -- are they prepared to deal with this? Are they going to have to sort of -- do you predict that down the road they're going to be rethinking this decision? What's it going to mean for them?

  • 10:27:45

    APPLEBYWell, the states that are opposed to expanding Medicaid raised concerns about cost. They say that they can't afford to expand their Medicaid program beyond what it is now. Now, the federal government would pick up 100 percent of the cost of these newly eligible people for the first three years, then it ratchets down to 90 percent of that cost, which is still more than a lot of folks are getting now. But there are still some costs. So they raised those concerns.

  • 10:28:07

    APPLEBYBut on the flipside, they've also got -- these governors that are opposed to raising Medicaid expansion are going to have to explain to folks why is it that people below the poverty level don't get any help and people just above the poverty level do. So they're going to have to explain that. And they're also facing pressure from the hospitals.

  • 10:28:22

    APPLEBYThe hospitals are very concerned about this because they made a deal that they would take slightly lower payment increases over the years in order to make this law work. They're going to expect it to get more people to have insurance. And this means people aren't going to have insurance necessarily in some of these states. So they're putting some pressure on the lawmakers in these states to say, hey, you've really got to expand Medicaid.

  • 10:28:44

    GJELTENJulie Appleby is senior correspondent for Kaiser Health News. And we're going to go right to the phones now. We don't normally go to the phones quite so early, but so many people have questions about these health insurance exchanges. We want to start dealing with them right away. First of all, Nancy is on the line from Dartmouth, Mass. Good morning, Nancy.

  • 10:29:02

    NANCYGood morning. You can hear me?

  • 10:29:04

    GJELTENI can hear you great.

  • 10:29:06

    NANCYI'm a little nervous calling. I live in Massachusetts. My husband is unemployed as I am myself. And we're dealing with a situation. It's a common household subject. Now, I've brought this up to my legislators because here in Massachusetts, we have the opportunity to be a model for the country.

  • 10:29:26

    GJELTENBecause you've already got some experience, don't you?

  • 10:29:28

    NANCYThat's right. We live under the system that's going to be implemented nationwide. Now, as a self-employed person, we make just enough to put us above the line to get subsidized health insurance. There's -- you either get MassHealth in our state, which is poverty, or you can make up to a certain income and get subsidized, which I believe -- don't take my word for it -- is about 50 percent.

  • 10:29:58

    NANCYNow, we make just above that. But what happens is they don't take into any kind of consideration what your expenses are. I have a child in college. I have a child in private school because there's learning difference. And so we really can't afford $1,000 a month. Now, it's $1,000 for a family of four, and there is absolutely no lower plan that I can get in Massachusetts and get my tax -- I don't know what you call it but allowance.

  • 10:30:29

    GJELTENYou -- OK. Now, Nancy, you're talking right now about Massachusetts' own program, right?

  • 10:30:35

    NANCYRight. So my question is, is it going to change for Massachusetts as well? Are we a model? Are you working off us? Are they creating these exchanges based around the exchange that already exists here?

  • 10:30:51

    GJELTENThat's -- OK. Let's put that question to Susan Dentzer. So Massachusetts is sort of unique in that regard. Does the federal law trump what Massachusetts is already doing?

  • 10:31:01

    DENTZERYes. And the subsidies that will be available under the federal law for a family of four, which I gather is what you are Nancy, go up to $94,200 in income for a family of four. So assuming that your income is below that level, your coverage will be at least somewhat subsidized. There will be a new exchange. The commonwealth connector essentially goes out of existence now and is replaced by a new Massachusetts exchange. So it'll be important to see what the premiums are that are listed on the exchange too.

  • 10:31:31

    GJELTENAnd, Julie Appleby, you want to add something.

  • 10:31:32

    APPLEBYIt's also important to remember that the subsidies range from -- depending on your income as well. So at the lower end of income scale, you're expected to pay at least 2 percent of your household income toward the premium, and at the upper end, it's 9.5 percent. So some folks are still going to have to pay a considerable amount of their household income toward the premium.

  • 10:31:51

    GJELTENOK. Let's go now to Scott who's on the line from Durham, N.C. Good morning, Scott.

  • 10:31:55

    SCOTTHi. Thanks very much for taking my call.

  • 10:31:57

    GJELTENYou bet.

  • 10:31:57

    SCOTTThe question I have as one of these people who got laid off from a company a couple of years ago, and so I'm part of that millions of Americans who don't have health care. I do make sure that my kids have it. I don't have it, and I'm healthy, knock on wood. But the real concern is that even though these exchanges will be available, even though these will be offered -- and it's wonderful to boon to anybody who really needs health care, and they're desperate, and they have health conditions.

  • 10:32:28

    SCOTTBut of a lot of us who won't be able to afford it and can't afford it now, even with the subsidy, we may not be able to afford it going forward. So it seems to me it's almost like the mortgage crisis where people got the mortgages and then the banker said, well, look, we'll just raise those rates, and they'll have to pay them. And instead, Americans walked away, and there's multiple foreclosures and failures of our system.

  • 10:32:56

    SCOTTSo I'm not so sure, you know, but it seems like the health care companies are sharpening their knives and forks going, boy, this is going to be great. Look at all these people who are going to have to pay the health insurance. And I'm saying, you know, I think a lot of Americans are going to say, gee, I don't have the money to pay for it now. Unless the federal government is going to be printing money and handing it to me to buy this insurance, I may not be able to afford it. I'll have to take the penalty. And...

  • 10:33:20

    GJELTENAnd, Scott, so you'll have to take the penalty. And how much of a burden is that going to be for you? And is it really worth it to pay the penalty rather than to get health insurance?

  • 10:33:31

    SCOTTWell, the penalty versus -- again, you know, this is where the money -- do I have $2,400? I mean, I'm hearing ranges of $190 to up somewhere in Vermont over $600 for a similar premium. The premiums vary. I don't know what those premiums are, and I hear about percentages. But it comes down to money. And it's a real issue for probably people like me and many other millions of Americans. Not that we don't want to have health insurance...

  • 10:34:02


  • 10:34:02

    SCOTT...we just haven't been able to afford it. Even if you say, congratulations, now, everyone's able to get it, well, great. Unless you're printing money, it may be ultimately a choice for us about saying, we'll take the penalty because we still can't afford it.

  • 10:34:16

    GJELTENAll right. Thank you, Scott. You're listening to "The Diane Rehm Show." And, Ceci, you can take that question. So I don't know how many people are out there like Scott who, even though they're going to have to pay a penalty, still said they can't afford insurance.

  • 10:34:30

    CONNOLLYSure. Now, until we actually see the numbers and people are able to do some of that math in terms of what income, if any, they have, the number of family members, what state they're in, age, et cetera, these are all going to be factors which will affect the pricing. The other thing is that someone like Scott who commented that right now, he's in good health, knock on wood, he might opt for something called a high deductible health insurance plan, which perhaps the first 1,000 or 2,000 or even up to $3,000 of the deductible would come out of his pocket.

  • 10:35:06

    CONNOLLYBut he's still protecting himself against some sort of catastrophic injury or illness. Those are sorts of things that I would encourage people like Scott and many of our listeners to take some time, look over the information. You don't have to sign up on Oct. 1. There's plenty of time to figure it out.

  • 10:35:26

    DENTZERThe other important point to make is that 80 percent of the people expected to buy coverage through the exchanges are going to be eligible for the subsidies. And the subsidies on average will be $5,000 per person. So there is real money on the table here to help people buy this coverage. I think Scott's comment points to a broader concern, which is that we all have a stake in lowering the rate of increase of health spending.

  • 10:35:51


  • 10:35:51

    DENTZERWe can't have health spending go up as much as it is. Health care cannot get as costly as it has been year after year after year. Part of the logic of getting everybody into the system, though, is so we all have a stake in this now. And we all can work with hospitals and physicians and others to figure out ways to delivery care much more cost effectively. So it is more affordable for all of us going forward.

  • 10:36:13

    GJELTENYou know, Julie, we have a tweet from Sean, who says -- asks, "Will there still be a tax penalty for those who self-pay for health coverage, those who are self-insured?" Well, is there really such as a thing as self-insurance in health care? Because unless you're Bill Gates or, you know, unless you're really, really wealthy, you're not going to be able to afford some catastrophic development in your healthy, right?

  • 10:36:39

    APPLEBYIf that's what he means by self-insured.

  • 10:36:41

    GJELTENIs there any other meaning to it?

  • 10:36:42

    APPLEBYWell, a lot employers are self-insured, and they do pay their own bills, and they usually have some kind of reinsurance. But for individuals, I think perhaps what he means is if he gets sick, he pays the hospital bill. And, you know, that will not actually be an exception. He does need to have a qualified health plan to meet the requirements of the health law.

  • 10:36:59

    APPLEBYAnd, you know, one other thing that I've covered over the years is people don't necessarily realize that when you don't have insurance and you do go to the hospital, they charge you an amount that's often much higher than what they would charge if you did have insurance. Because insurers negotiate with hospitals, right?

  • 10:37:14

    APPLEBYThey negotiate for certain rates. So those rates are lower than their sticker price charges. But if you go in there without insurance, you might well be paying much closer to those sticker prices charges. So even if you are saying you're going to pay the bill yourself, you will probably pay a much larger bill as a result.

  • 10:37:31

    GJELTENJulie Appleby is senior corresponded for Kaiser Health News. My other guests are Susan Dentzer, senior policy adviser at the Robert Wood Johnson Foundation, and Ceci Connolly, managing director of PwC's Health Research Institute. Ceci is also the co-author of "Landmark: The Inside Story of America's New Health Care Law and What It Means for Us All." And that's precisely what we're talking about in this hour of "The Diane Rehm Show." We're going to take a short break now. When we come back, we'll take more of your calls. Thanks for listening.

  • 10:40:24

    GJELTENWelcome back. I'm Tom Gjelten, sitting in today for Diane Rehm. And we're talking about the health insurance exchanges that are going to go into operation on the 1st of October. And I have to say I've never seen as many calls and emails coming in from listeners with questions and comments, mostly questions I have to say, about this program. We'll try to get to as many of your questions as we can.

  • 10:40:46

    GJELTENWe've been talking -- before the break, we were talking a lot about people who are uninsured right now. Let's talk a little bit now about people who actually have access to insurance through their employers but still have questions about their options going forward. Again, my guests are Julie Appleby from Kaiser Health News, Susan Dentzer from the Robert Wood Johnson Foundation, and Ceci Connolly, managing director of PwC's Health Research Institute.

  • 10:41:15

    GJELTENSo a couple of -- first of all, a couple of email questions here, very similar. Larry says, "My son works for a company that offers insurance with poor coverage and high premiums. Can he go to the exchange to find a better deal?" Similar question from Cathy, she says, "My company offers family coverage for an additional $1,300 per month which we can afford. What are our options?" Julie.

  • 10:41:39

    APPLEBYThe short answer is, yes, they could go to the exchange. The long answer is they may not qualify for a subsidy on that exchange if they're offered coverage through their employer. And what that means is that if your employer offers coverage that's considered not comprehensive, it doesn't cover at least 60 percent of the cost of your care, or it is more than a certain percentage of your household income, which is 9.5 percent of your household income, then you may indeed qualify for a subsidy on the exchange.

  • 10:42:11

    APPLEBYOtherwise, if you're offered job-based insurance, which is the way most people in America get their health coverage, you are not eligible for a subsidy on the exchange. You could go there and look and see what the costs are. Generally, your employer coverage is going to be less expensive to you because the employer picks up a pretty good portion of the cost of that coverage.

  • 10:42:30

    GJELTENBut not -- that's not necessarily true. I mean, it is possible that you might find a better deal on an exchange than what your employer has offered.

  • 10:42:38

    APPLEBYIt is possible. Yes, it is possible.

  • 10:42:40

    CONNOLLYParticularly, Tom, if you are a low-wage worker or perhaps you have part-time or seasonal work, then doing that math and looking at the subsidy could benefit you.

  • 10:42:52

    APPLEBYBut that's only if you qualified for the subsidy though, then you'll have it.

  • 10:42:54

    DENTZERIt's also important to take up that second caller's question or situation because there are circumstances where even if an individual obtains coverage through an employer but the family coverage is not provided, families -- family members cannot go into the exchange and get coverage with subsidies. That's a flaw in the law that probably wasn't intentional, as most flaws would not be intentional.

  • 10:43:19

    DENTZERAnd recently, President Clinton, who is making speeches on the law, underscore that that was one of the issues that needed to be fixed so that family members could go into the exchange and buy coverage with subsidies if they were in this situation.

  • 10:43:33

    GJELTENOK. One more email question before we go back to the calls. And this is from an employer, from Ann, who says, "We have a very small business. Our current health care group consists of two partners in the firm. For a very small business, does it make more sense to allow individuals to get insurance through exchanges than to offer a group plan for employees?"

  • 10:43:55

    GJELTENNow, I'm assuming -- so this is an employer who is not obligated to provide health insurance for her employees. They want to provide health insurance, and they are asking, does it make sense for us, as employers, to just let the employees go to an exchange or to try and put together something ourselves? Ceci Connolly.

  • 10:44:13

    CONNOLLYWell, I think, judging on that -- by that description, that there might be a third way in this circumstance which would be to go on to the small business exchange. Some people refer to it as the shop exchange where there is a hope that there will be some better rates available for small businesses than what they see today. Some states are in a better position on the small businesses exchanges for 2014, but that is another option.

  • 10:44:42

    APPLEBYIt's a good time for small businesses in that situation to talk to an insurance broker who's knowledgeable about all facets of the market. What's available on the individual exchange, what's available on the small business exchange and what also might be available because insurers are now selling into a new market that they've never sold into before.

  • 10:45:01

    GJELTENBut we've been talking about how confusing this is for individual insurance buyers, and it's also a challenge for employers, isn't it, as they confront this new regulation.

  • 10:45:08

    APPLEBYYes, it is.

  • 10:45:09

    GJELTENLet's go now to Claire, who's on the line from Fairfax, Va. Good morning, Claire. Sorry you had to wait so long.

  • 10:45:15

    CLAIREHi there. No problem.

  • 10:45:16


  • 10:45:16

    CLAIREI wanted to clarify with the panel, isn't it true that when designing this law, Obama made a deal with the insurance companies that they could charge individuals over 55 up to 3 1/2 to four times what they could charge those under 55? And the over 55, of course, is a segment of the population most in need of health care. So could they all clarify that issue?

  • 10:45:44

    GJELTENJulie, isn't it just the opposite of what Claire says that younger people will pay more than older people?

  • 10:45:48

    APPLEBYThe law actually sets a ratio. So the law allows insurers to charge older people up to three times more than younger people. And this actually puts into place a cap. Right now, states vary on what they require insurers to do. Some states have no rules on this at all. Some states allow insurers to charge older people as much, you know, five, 10, 15 times more than younger people if they want. Other states have capped it.

  • 10:46:14

    APPLEBYThis law caps it at 3-to-1. The insurance industry actually wanted it to be 5-to-1 so that they could charge older people five times more than younger people. But the law does say 3-to-1 and that again starts Jan. 1.

  • 10:46:27

    GJELTENWell, how does that compare, Susan, to situation now? If you're over 55, what are your premiums going to be as opposed to someone who's much younger?

  • 10:46:36

    DENTZERYour premiums are -- it is hard to state this succinctly, but let me say that for most people, the premiums available to them now, if they're older, will be lower on average than were available previously because of the situation that Julie described. Many people were paying 7-to-1, 8-to-1. Now, it is 3-to-1. So premiums, on average, will be lower. It's also important to note that for women, on balance, also premiums will be lower.

  • 10:47:06

    DENTZERWomen, historically, have been charged more for various reasons, not the least of them being that women give birth to children. And so insurers were charging women in effect for that extra cost. That goes away under the law. So again, depending on your gender, your age, on balance, for older people, premiums are going to be lower. On balance for younger people, premiums will be higher, but the coverage will probably be more generous than they were seeing previously.

  • 10:47:35

    GJELTENSo there is going to be some subsidization, if that's the right word, of older people by younger people under this program, more than there is now.

  • 10:47:43

    DENTZERYes, I think that's fair to say on the theory that the best -- and in the best of all environments, younger people eventually grow up to be older people.

  • 10:47:51


  • 10:47:51

    DENTZERThat's success, right?

  • 10:47:52


  • 10:47:52

    DENTZERSo we ought to basically enshrine that into the law and have people pay split -- share these costs broadly across the population.

  • 10:48:00

    GJELTENAnd that's how we pay for Social Security, isn't it? The younger workers are paying for older workers. Susan's on the line from Saugatuck, Mich. Good morning, Susan.

  • 10:48:06

    SUSANGood morning, Tom, and good morning to your guests. I am a self-employed person who has carried insurance for myself for well over 15 years with the same company. I pay way over $8,000 a year. That does not cover my medical visits to my doctor or my prescription drugs. And I'm very concerned about the situation because when I look at these exchanges and the option to change, I know that, generally, there is a waiting period with new insurance.

  • 10:48:39

    SUSANAnd so I'm calling with two questions. One is, is there provision built into the law so we do not have to wait after we change to a new company? And if there isn't, then what does one do if they're in the middle of a medical situation with an old company and they want to change to a new company, but the situation for the waiting period provision is not there?

  • 10:49:02

    GJELTENCeci Connolly.

  • 10:49:03

    CONNOLLYSo I would say, Susan, if you're interested in making a switch and you want to look at what's available on your exchange, this fall is the time to do it. This is the open enrollment period beginning October. It'll carry through to the end of March. But if you want to have that insurance in place on Jan. 1, you want to go and look and try to sign up before that date so that it kicks in for the full 2014.

  • 10:49:29

    DENTZERAnd there is no waiting period. As of Jan. 1, you'll be fully covered under your new plan.

  • 10:49:35

    GJELTENI want to go to a emailed question now from Cynthia. And she asks, "Will insurance companies still be able to offer a premium price? Then after the underwriters take your medical history, change -- charged a higher premium, will the premium price listed on the exchanges be the final set price of the premiums?" Ceci.

  • 10:49:59

    CONNOLLYTom, that's -- that, I think from a consumer prospective, is one of the best elements of the Affordable Care Act that you cannot be denied coverage or even have your premium set based on your health status.

  • 10:50:12

    GJELTENMm hmm. Except for -- there are few exceptions, right? If you're a smoker, it does count.

  • 10:50:17

    CONNOLLYThat's right. Yes, yes.

  • 10:50:20

    DENTZERBut that's the only one. And it's 1 1/2 times as the allowable increase in the premium versus a nonsmoker.

  • 10:50:28

    GJELTENOK. Let's go now to -- Russell is on the line from Hanover, Pa. Good morning, Russell.

  • 10:50:32

    RUSSELLGood morning.

  • 10:50:34

    GJELTENYou had a question or comment?

  • 10:50:36

    RUSSELLYeah. I have a comment. You know, I wanted to shed some light on the, you know, from a different prospective on the health care, health insurance matter. You know, I think the way ultimately around the entire problem is to quit participating. You know, health care companies, health insurance companies, they're in it for the profit. They have no concern for our health. That's the front that they want you to focus on so that they can get your money. I believe that doctors should be like every other service.

  • 10:51:15

    RUSSELLWhen you call a plumber, you negotiate the price and you pay cash. You know, I understand that there are, you know, astronomical surgeries that costs, you know, way more than some people can afford, but those are few and far between. And I believe we would find that if we reverted to a system like this, where doctors were, you know, a service call, you would find that a lot of those numbers will go down because in the other industry, you know, when there's a shortage, when there's a demand, the price goes down, you know, the cost diminishes.

  • 10:51:53

    GJELTENWell, Russell, you're calling the question, the whole idea of insurance generally, not just for a health care but insurance for everything.

  • 10:52:00

    RUSSELLYeah, really. Because, well, you know, health care is the main one, because we spend so much money on health care for just in case something happens. And, you know, a lot of times we go our whole entire life, and nothing ever happens.

  • 10:52:15

    GJELTENWell, that may be true for some people. But for a lot of people, stuff does happen. Doesn't it, Susan?

  • 10:52:20

    DENTZERWell, and also you probably have homeowners insurance, and it's not because you expect or hope that your house will burn down. It's there in case -- you have it hoping that you will never need it. I think the important point is that we are slowly becoming more conscious of costs of health care in part because of the phenomenon Ceci described.

  • 10:52:39

    DENTZERA lot of people have high deductible health plans, so they are paying out of pocket and they are doing more shopping around. And there are companies now in existence -- one is Castlight, another is OkCopay -- that will actually show you what the costs are if you go to various different physicians or hospitals, and if you have to pay out of pocket or if you have to pay the copay out of pocket, which often matters to people as well.

  • 10:53:03

    DENTZERSo we're slowly getting a little bit more conscious of the costs. We need to get more conscious of the cost. But I think truly one would be playing with fire right now if you elected to go without health coverage given the cost of health care, especially if you have serious health care needs.

  • 10:53:18

    GJELTENSusan Dentzer is an on-air analysis on health issues at "PBS NewsHour." I'm Tom Gjelten. You're listening to "The Diane Rehm Show." All right. Let's see. Let's go to Mallory, who's on the line from Evansville, Ind. Good morning, Mallory.

  • 10:53:34

    MALLORYGood morning. I don't really have so much a question. I was wanting the panel to speak to a certain group of people. My husband has health insurance through his job, but it would costs $850 for them to add me and my infant daughter on to the plan. We probably -- I live in Lafayette, Ind. which has been in the news as fudging the numbers actually as to what the subsidies would cost. But even at 200 or $300 a month, my husband and I both pay three to $400 a month in student loans.

  • 10:54:11

    MALLORYSo there is this group of people who are already suffering under new staggering student loan debt that might qualify for subsidies, but still it's unfeasible for us to be able to pay that. And I was just wondering, are there going to be certain caveats for student loan debt? Or, I mean, just what people, in my position who are just starting out with families, who are trying to save money to buy houses and to be, you know, participating members in society like our parents were, like they just -- I just don't know what we're supposed to do.

  • 10:54:46

    GJELTENOK. So let's summarize Mallory's question as saying, what are the criteria that really go into defining how much subsidy an insurance buyer is going to get? What are the sort of the factors that -- or the formula that sets that? Ceci.

  • 10:55:03

    CONNOLLYWell, the most important thing is going to be their income level. And unfortunately, I am not aware of any deduction if you have to pay student loans, so that will not be a factor. Then the price of your health plans -- the ones that you can go ahead and take a lot on these marketplaces as they're sometimes also called -- will vary.

  • 10:55:27

    CONNOLLYYou know, we've been talking about differences between younger and folks and retirees, potentially price differences there. It will depend what state you're in as well. So these are all factors that are going to into the equation and presumably you'll have some choices.

  • 10:55:45

    DENTZERIt's also important, I think, to note in your situation, Mallory, if your husband has coverage, you're probably going to be stuck with the coverage available through the employer. You might be in the situation where you would not be able to go to the exchange to get coverage for yourself and your child alone. It's a good time to talk to a navigator or someone who could help you through that whole situation.

  • 10:56:08

    APPLEBYShe might be able to get a plan on the exchange but without a subsidy. And I'm just looking at some data that came out recently. It looks like a second-lowest cost silver plan in Indianapolis is around $295 a month for a single person. So I'm not sure how much more it would be to have the child on there as well, but might be less expensive than going through the employer.

  • 10:56:25

    GJELTENThere's one other issue. We're just about out of time, and somebody has a real quick comment. I appreciate it. And that is that companies like IBM and Time Warner, who have been providing insurance to their employees are now looking at hiring a company to set up an exchange for them. Julie.

  • 10:56:40

    APPLEBYThis is for retiree coverage. And what they're doing over at IBM is what a lot of companies done. They've really cut back on retiree coverage. Very few companies currently offer retiree health coverage. It's been on the decline for a while. And what IBM has done is said that they're going to give a certain amount of money to their retirees. Their retirees are going to go to a private exchange and buy their own Medicare-type coverage on that private exchange.

  • 10:56:58

    GJELTENMm hmm. And IBM -- but IBM will designate the exchange that they are to use, correct?

  • 10:57:05

    APPLEBYIt's going to go through one of these private exchanges.

  • 10:57:07

    GJELTENAll right.

  • 10:57:07

    DENTZERAnd they have picked that. And it's important to note, those are different exchanges from the marketplaces that we've been talking about today, which are the ones set up under the Affordable Care Act.

  • 10:57:16

    GJELTENRight. Susan Dentzer, she is the senior policy adviser at the Robert Wood Johnson Foundation. My other guests have been Julie Appleby, senior correspondent at Kaiser Health News, Ceci Connolly, managing director of PwC's Health Research Institute. Earlier in our program, we heard Tim McKinney. He is the president and CEO of United Way in Tarrant County, Texas. And we're going to return to this subject in future programs, but, for now, that's it. I'm Tom Gjelten, sitting in for Diane Rehm. Thanks for listening.

  • 10:57:46

    ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Denise Couture, Susan Casey Nabors, Rebecca Kaufman, Lisa Dunn and Danielle Knight. The engineer is Erin Stamper. Natalie Yuravlivker answers the phones. Visit for audio archives, transcripts, podcasts and CD sales.

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