MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Health insurance coverage through the Affordable Care Act began yesterday. More than 2 million Americans have enrolled in private sector health insurance through the state and federal exchanges. But in a new challenge to the Obama administration, the Supreme Court blocked implementation of the ACA's contraceptive coverage requirement.

MS. DIANE REHMJoining me to talk about the latest on the healthcare.gov rollout, Susan Dentzer of the Robert Wood Johnson Foundation and Julie Appleby of Kaiser Health News. Do join us. I know many of you have questions, comments. Give us a call at 800-433-8850. Send us your email to drshow@wamu.org. Follow us on Facebook or Twitter. And Happy New Year to both of you.

MS. SUSAN DENTZERHappy New Year, Diane.

MS. JULIE APPLEBYHappy New Year.

REHMThank you. Good to see you both. Julie Appleby, what gauges can be used to tell us how well the ACA is doing?

APPLEBYWell, you know, it's a new year, and the administration is hoping for a new narrative. So, earlier this week, they had a press conference where they talked about enrollment, and enrollment has picked up in December. It's now, as you mentioned, about 2.1 million or so people nationwide. So that's one gauge, and those are fairly decent numbers, especially when compared with October and November.

APPLEBYBut October and November were pretty dismal, so that was a pretty low bar. So the administration, though, is hoping that this shows that the fixes they've made to healthcare.gov have worked, that people are able to sign up. They are also pointing out that, you know, people still have until March, the end of March to enroll. So that's one gauge. Other gauges are going to come down the line when we see, you know, how many people do enroll by March, what kind of a mix those folks are. Are they mostly healthy? Are they mostly older and sicker? So we'll see different things as this plays out.

REHMBut it would seem to me that it's a pretty remarkable comeback from what it seemed in October and November.

APPLEBYThere was a really big surge. In fact, they said that on the day before Christmas and -- Christmas Eve and the day before, they had 2.8 million visitors to the website. And in the month of December alone, they had 975,000 people sign up through the healthcare.gov site, which, remember, it's in 36 states. They're running it for 36 states. So those are big numbers compared with October and November.

REHMJulie Appleby, she's senior correspondent with Kaiser Health News. Susan Dentzer, can we truly expect the program to reach enrolling 7 million by the end of March?

DENTZERWe don't know, Diane, honestly. It is the case that if we've had more than 2 million particularly in this later period, it's reasonable to expect at least that additional number, I think, to enroll between now and the end of March. All past precedent tells us people put this off until the last possible minute. A lot of the people who bought coverage, even through the federal marketplace, actually had coverage previously.

DENTZERWe know this from some of the data that's emerged, so these were people who were not uninsured before now. They were buying insurance on the individual insurance market, and they've converted over to the products available now through the marketplaces. So there still is a large pool of uninsured people who probably are continuing to take their time.

DENTZERThere was a lot of confusion about the law. The other important point here is that we've had about 4 million people enroll in the expanded Medicaid program, a very important part of the expansion of coverage in the Affordable Care Act. And that's -- as you can see, that's double the number that it signed up on the marketplaces. So the Medicaid expansion, even given the fact that half the states have not so far expanded their Medicaid program, that is showing some very strong enrollment also.

REHMSo what about the insurers themselves, the insurance companies? What are they doing to prepare for this extraordinary rollout?

DENTZEREverything possible to make it work. The fundamental point, of course, is that the insurance industry supported the law because it saw this as the last gasp of private health insurance in this country. And so if this law doesn't work, it's not clear what comes after that. So a number of workarounds, a lot of the insurance companies have said that if they get the first month's premium by Jan. 10, they're going to offer coverage retroactive to the first of the year, which is not usually the case.

DENTZERUsually, you have to pay your insurance premium by the 15th of the month in order to have coverage starting the following month. So that's a big workaround. They're also continuing to work out some of the glitches that continue to crop up as enrollment -- people enroll on the marketplaces, but the information doesn't get to insurers in a timely way.

DENTZERAnd so they're working out a lot of those issues as well. And then, finally, of course, a very big workaround in the law was that people who got their policies cancelled because they were not compliant with the Affordable Care Act, those people now also can apply for a barebones form of coverage and claim, in effect, exemptions under the affordability requirements of the law. That's something insurers weren't thrilled about doing, but they understand politically -- I think many of them -- that it's necessary to do that.

REHMSusan Dentzer, she's senior policy advisor with the Robert Wood Johnson Foundation and on-air analyst on health issues with the "PBS News Hour." I know many of you have questions, comments. Do join us, 800-433-8850. What about the news from the Supreme Court, Susan Dentzer? Sonia Sotomayor and several other courts weighed in on this contraceptive provision.

DENTZERThat's right. Of course, under the law, insurance plans have to cover preventive care, and one aspect of preventive care is women's reproductive care. Specifically contraceptive coverage has to be covered with no co-pays to the individual insured. Because this was extremely controversial from the start, especially among Catholic institutions and...

REHMOf course.

DENTZER...Catholic-affiliated institutions, the administration offered a compromise, which is, in effect, that those institutions don't have to actually pay for this coverage themselves. The coverage is paid for, in effect, by the insurer that offers the coverage. So, technically, this exempted all of these organizations from actually having to pay for the coverage, offer the coverage themselves.

DENTZERThis compromise, nonetheless, was still found to be insufficient by a number of Catholic-affiliated organizations, and so what Supreme Justice Sonia Sotomayor did on New Year's Eve was issue a temporary stay against the enforcement of this provision of the law as it applies to some of these Catholic-affiliated organizations that continue to argue that this is a violation of the law, specifically the Religious Freedom Restoration Act.

REHMJulie, were you at all surprised to hear that come from the Supreme Court?

APPLEBYNot really because there are so many of these cases that are now working their way through the courts. Many of them have to do with for-profit private business. But there's also a number of these religiously-affiliated groups that are very concerned about this requirement. So I think that they know it's ultimately going to end up at the court, so it wasn't that terribly surprising.

REHMHow do you think it's going to affect the rollout, Susan?

DENTZERIt will have some effect. It is important to note that most of the Catholic-affiliated institutions signed onto the compromise, so the Catholic Health Association, which represents the nation's Catholic hospitals, agreed with the compromise. So this is a minority of the Catholic-affiliated set of institutions now that continue to make this argument.

DENTZERHowever, if, in fact, after reviewing the government's brief, which is due on Friday morning, the justices decide to continue the stay because they anticipate that the Supreme Court will eventually have to decide this issue as well then we don't really know what's going to happen, whether other Catholic institutions would also decide to suspend coverage for the moment...

REHMInteresting.

DENTZER...or whether they would proceed. I would personally bet that many of them will continue to proceed to offer this coverage because they sought the compromise, they achieved the compromise, and that's what they want. But, as we see, there is still a significant group that will not provide the coverage.

REHMJulie.

APPLEBYI think that's the case. I think the concern that the Little Sisters of the Poor have expressed is that even though there is this...

REHMIn Baltimore, by the way.

APPLEBYRight. They also -- they're in Colorado as well. And what they've expressed is that, even though there is this workaround, they have to self-certify. They have to sign a paper that says, you know, this violates our religious beliefs, and then that would kick it over to this alternative where the insurer would cover the costs of the contraceptives. And then they get reimbursed eventually. So it's not directly coming out of their funding, but they say that, in itself, violates their religious beliefs because they are, in effect, authorizing the dispensation of contraceptives, which they don't believe in.

DENTZERAnd the insurer, in this case, is also a Catholic-affiliated insurance company that offers this coverage to Catholic-affiliated institutions like the Little Sisters of the Poor.

REHMSo your prediction is that the majority will move forward, but the minority will abide by the Supreme Court's stay and wait for the judgment that comes when, on Friday?

DENTZERWell, who knows? Who knows?

REHMAs early as Friday perhaps?

DENTZERBut what, as Julie says, what one has to assume here is that the -- Justice Sotomayor, by the way, hasn't said why she issued the stay. But one has to assume that it's because she or other justices believe that some appeals court will eventually rule in favor of the plaintiff and that this will end up at the Supreme Court.

REHMSusan Dentzer, Julie Appleby, both here to answer your questions. I know you have many. We'll open the phones as soon as we come back. Stay with us.

INTERVIEWERAnd welcome back. We're talking about the rollout of the Affordable Care Act. Millions of people have now signed up. The question though still remain, many, many questions about who will actually receive the insurance promise by the Affordable Care Act. I said I would open the phones immediately, and I'm going to do so. We'll work in as many of your calls, comments as we can. First to Alexandria, Va. Hi there, Kyle. You're on the air.

KYLEThank you so much, Diane, for taking my call. I'm very excited to be talking to you today.

INTERVIEWERCertainly. Thank you.

KYLEI was calling -- I had a question actually about a situation that I find myself in now where, with the Affordable Care Act, there's a subsidy if you make a certain amount of money. I actually don't qualify for that subsidy. And because I live in Virginia where they did not roll out the expansion of Medicaid, as was suggested by the Affordable Care Act along with a number of other states, I actually fall into a sort of gap where I can't qualify for health insurance either through the Affordable Care Act or through Medicaid.

KYLEAnd I know that there's a number of other states out there that have also -- this gap kind of occurs in. And I was wondering if you or your guests could comment on how many Americans are affected by this gap and what plans there are to fix it in the future.

INTERVIEWERKyle, I'm glad you called. Julie.

APPLEBYThis is a problem in about half the states because only 25 states and the District of Columbia expanded Medicaid. So people like Kyle who earn less than 100 percent of the federal poverty level don't qualify for a subsidy on the exchange, and they don't qualify for Medicaid because Medicaid hasn't been expanded.

REHMKyle, can you tell us how much you do earn?

KYLEWell, it's less than $10,000 a year -- annually.

REHMWow.

APPLEBYRight. And federal poverty level is about $11,490 for an individual. So if you're below that 100 percent level and you're in one of these states like Virginia that haven't expanded, then there aren't any options for you to get a subsidy or to get Medicaid. So the law does say that people like Kyle aren't going to be hit with a penalty fine for not having insurance. He would get an exemption obviously from one.

REHMBut how does he go to the doctor, Susan?

DENTZERWell, one piece of good news for Kyle is that the new governor of Virginia, Terry McAuliffe, intends to expand the Medicaid program and has the ability, as I understand it, under Virginia law to do that through the Virginia budget, doesn't have to adopt a new law.

REHMAs opposed to the legislature.

DENTZERRight. Exactly. So Kyle probably will get some relief, one presumes, later this year. That is not necessarily going to be the case in all the other states that have decided for the moment not to expand Medicaid (unintelligible) sense.

REHMSo how soon would you think the governor might act on that?

DENTZERWell, it was a signature part of his campaign, so one assumes it will happen pretty expeditiously.

REHMAll right, Kyle. Hold on. It may be coming sooner than you think. Thanks for calling.

KYLEThank you so much.

REHMAll right. Bye-bye. And let's go to Steve in Cambridge, Mass. You're on the air.

STEVEDiane, the ACA classifies smoking as a behavior whereas it classifies, let's say, drug addiction or obesity as preexisting conditions. My -- and because smoking is classified as a behavior, insurance companies can charge a lot more. My question to your guests is, one, why -- what is the rationale for that distinction, and, two, could not many poor smokers be priced out of insurance?

REHMSusan Dentzer.

DENTZERFrankly, it was a political decision that essentially looks back at the trajectory of what we -- the history of what we know about smoking and the connection between smoking and disease and the decision that there ought to be at least one behaviorally-related condition that people have to pay more for in order to obtain insurance coverage. Does it make a lot of sense? Probably not given what we know now about nicotine addiction and the effects on the brain and how nicotine operates on the brain much like any number of other substances that are legal operate under the brain.

DENTZERSo -- but be that as it may, it's what's in law. And I think the other -- the only consolation, I guess, is that also covered for free under all policies now will be smoking cessation at no cost to individuals. So people now have an ability to actually get the kind of assistance they need to break the addiction to tobacco.

REHMJulie, do you see this policy changing?

APPLEBYYou know, we've seen a number of these kinds of policies in job-based insurance as well, so this is not new. So I don't know if this is going to change. I think a number of insurers or states have said that they're not going to allow the enforcement of the additional surcharge. I'm not entirely sure which states are, but there's been some of that discussion. But the concern is that people who smoke aren't going to seek coverage because of this cost. And you really do actually want them to have healthcare coverage.

REHMInteresting. All right. Let's go to Jim in Houston, Texas. You're on the air.

JIMThanks, Diane, for taking my call.

REHMSure.

JIMI've got a couple of concerns. My wife is in healthcare and Houston is a pretty large healthcare area. And we've seen a significant number of doctors opting out of insurance plans, going to concierge services, especially internal medicine doctors. As a matter of fact, the last graduating class of the Baylor College of Medicine had 200-plus internal medicine residents come out of there. And only two of those chose to go into primary care internal medicine.

JIMAnd when you look at the entire program here and just how unclear and turgid the regulations are, I think we're going to find ourselves with an extremely high number shortage of doctors, especially in internal medicine and psychiatry. And it concerns me. And knowing as many healthcare professionals as I do, there's -- the talk amongst the healthcare industry itself is not very good when it comes to this program because of the constantly changing exceptions, the enormous amount of adding 30-plus million new people into a system that's already stressed to the max.

JIMSo I think that we're really looking at probably, as someone said earlier, the end of private insurance. And, in my opinion, hopefully when this is all shaken out and over with, we'll probably end up with Medicare for everyone, which is where we should've started in the beginning.

REHMWhat do you think, Julie? A lot of people feel as our caller does.

APPLEBYThere's a lot of people who are concerned both about a doctor shortage and also the fact that they would've preferred to see a single-payer type of program.

REHMAnd don't you think the president himself would have liked that from the beginning? We can't really speculate but there was indication that that would've been his preference.

APPLEBYYeah, don't really know what his preference would've been but politically they just felt that that could not happen right now. And given all the controversy over this law as it's played out, which this law has a number of Republican ideas in it as well as Democrat ideas.

REHMOf course.

APPLEBYAnd still it's very controversial, and Republicans did not sign on to this law. So I don't see how they could've gotten folks to sign on to a single payer.

DENTZERJust to go back to the question of whether newly insured people will have sufficient access. It certainly is the case that we have underpaid primary care in this country, whether delivered by doctors or others. And we're in the process slowly of redressing that so that hopefully over time people will find primary care a more attractive occupation to go into, particularly if they're physicians. However, it's also the case that we have been gearing up a lot of capacity to see people newly becoming insured. The federally qualified health centers are expanding.

DENTZERMany systems across the country have graded patient-centered medical homes. It's also the case that, frankly, hospital use is declining across most of the country. Hospitals are going to be looking for business, and even if that means figuring out a way to deal with some of the needs of newly insured people.

REHMWhy are hospital usages going down?

DENTZERWell, because some other aspects of the Affordable Care Act are working. And these are basically under the radar for much of the public. But one of the big set of initiatives was to reduce so-called avoidable readmissions into hospitals. This is when people might be hospitalized for, say, a chronic condition like congestive heart failure. They go home. They don't necessarily understand their discharge instructions or their medication regimens, and they end up back in the hospital within 30 days.

REHMSo it's up to the doctors and the hospitals to make sure they understand before they release them now.

DENTZERThat's right. And in 2012, penalties were put in place for hospitals that have above a certain threshold of these avoidable readmissions. The net effect has been that these avoidable readmissions are down, and admissions are down across much of the country.

REHMAnd what's interesting -- because I've been traveling around the country in this past year -- is that hospital construction is up. I don't get it.

DENTZERWell, a lot of people don't get it. And a lot of people think that many hospitals -- well, for -- some hospitals obviously need to redo their existing physical plant and update it to more modern standards. But in other areas of the country, there's clearly a disbelief that this design in utilization is going to persist over time. We'll see. It does look as if the trend to lower utilization is happening.

REHMInteresting.

DENTZERAnd it's going to be sustained on the inpatient's side.

REHMJulie.

APPLEBYAnd you're also seeing a building boom in suburban areas where people are more likely to be insured as well. So that's where a lot of this growth is also happening. Hospitals are being very particular about where they build these new facilities.

REHMOK. Let's take a caller in Gettysburg, Penn. Hi there, Bruce.

BRUCEHi, Diane. Thanks for taking my call today.

REHMCertainly.

BRUCEI called because I'd really like to hear the experts' kind of comment on my situation. When I listen to the news and to different shows like this, it feels to me like the media has kind of bought the whole thing hook, line, and sinker. I'm a 51-year-old self-employed -- successfully self-employed person, computer savvy. I've been working with healthcare.gov since Nov. 1.

BRUCEI filled out three applications online, two on the phone, and I've logged over 20 hours on the phone -- and it's not hyperbole, this is actual logged numbers -- 20 hours on the phone with healthcare.gov representatives. I still, to this day, cannot view my eligibility results. And what they want me to do is make a decision over the phone and discuss with them what the healthcare options are over the phone, which will probably take a good six hours or more -- longer, and send them my income verifications via snail mail.

BRUCEAnd I feel like that -- well, just to finalize that, I pressed them pretty hard the last time. And the lady told me -- she said, well, to be really honest with you, sir, no one's actually signed up online completely. It requires you to sign up over the phone. And that's how the people who have signed up thus far have signed up. And...

REHMI'm not sure of that, Bruce. Our panelists are both shaking their heads. Susan.

DENTZERWell, clearly many people have succeeded unfortunately where regrettably it sounds like you have not been able to break through. I'm just curious. Why the resistance? Why don't you go ahead and send in the information and get it over with?

BRUCEWell, I could respond to that. I mean, I feel like this is a family decision when I sit down with my wife and we look at the different plans with the PDF document in front of us telling us exactly what it covers. I mean, it's the kind of thing where I would really love to see my eligibility results, but right now I can't even view my eligibility results (unintelligible)...

APPLEBYYou mean eligibility for a subsidy or for coverage?

BRUCEFor a subsidy and for coverage. I mean, I don't -- I assume that they're part and parcel of the same thing. The eligibility for coverage and also for subsidy is on the same piece of paper. I mean...

REHMSusan.

BRUCE...it's so frustrating just (unintelligible)...

REHMOK. Hold on, Bruce. Susan.

DENTZERWell, if you're self-employed, you're obviously not being offered coverage through an employer. So you're eligible on those grounds. So the only remaining question would be the subsidy that would be related to your income.

REHMDepending on how much he earns.

DENTZERYeah, and you should be able to calculate that based on what your income is likely to be.

REHMBruce, how much do you earn?

BRUCEAbout 62,000 a year.

REHMOK. So where does that put him?

DENTZERYou'll be eligible for a subsidy because the subsidies extend to families of four up to $95,000.

REHMDo you have a family of four, Bruce?

BRUCEYes, we do.

REHMOK.

DENTZERRight. So you'll be eligible for a subsidy. That should be a pretty straight-forward calculus. So then the only question is, you know, what plan do you want to be enrolled in?

REHMAnd that's what you and your family need to figure out. I think, from there, on it ought to be pretty straightforward. Wouldn't you say?

APPLEBYThis illustrates why for some people it's been really difficult to sign up for coverage and why people who are signing up may well be folks who have a health condition because they're the ones that are going to stick this out. Now, what Bruce could do is get his list of plan options off of healthcare.gov. You can see plans in your area. It gives you some of the details about the plans, whether they're deductibles, what do they cover, what doctors are in the network, and you could sit down with that and his family and look at those and choose one of them.

REHMJulie Appleby of Kaiser Health News, and you're listening to "The Diane Rehm Show." All right. Let's go to Glocester, R.I. Hi, John, you're on the air.

JOHNHi, Diane.

REHMHi.

JOHNYeah, I just want to say, if the Catholic Church can get exemptions for stuff like contraception, what about people that are business owners and things that are, like, Christian Scientists that don't believe in using any medical intervention? Why should -- by the same argument, why should they have to buy healthcare for their employees at all?

REHMInteresting question. And what do you think, Susan?

DENTZERWell, this is, I think, what the court -- it's probably behind the court's reasoning that they're going to have to be making some determination ultimately about what the Religious Freedom Restoration Act really does say in this instance. The law -- that particular law asks that organizations that believe that their religious rights are being infringed upon have to demonstrate a substantial burden that their religion is being infringed upon.

DENTZERAnd then also the government has to demonstrate a so-called compelling government interest using the least restrictive means to accomplish a goal like providing contraceptive coverage. And so those are the kinds of issues that the court appears probably likely to say, we really need to decide is this a substantial burden and on whom is it a burden and what do you have to do to demonstrate that it's a burden?

REHMAll right. And...

DENTZERAnd also is there a compelling interest on the other side on the part of the government to make sure that women have access to contraceptive.

REHMOne last quick question from Jeremy before the break. Hi there. You're on the air.

JEREMYHi, Diane. Thank you for taking my call.

REHMSure.

JEREMYI was wanting to -- how many hospitals in America are actually religiously-affiliated? And how many women are affected by this recent injunction?

DENTZERWell, I don't know the number off the top of my head.

REHMI thought it was about 600.

DENTZERIt's probably more than that, but unfortunately one of the reasons that this is hard is there's been a lot of consolidation of hospitals into systems. So there are very large Catholic hospital systems, Ascension, for example, one of the largest in the country, Catholic-affiliated institutions on the non-profit side. But, as I say, most of those institutions went along with the compromise that was offered by the administration about contraceptive coverage.

REHMSusan Dentzer, she's with the Robert Wood Johnson Foundation, also on-air analyst on health issues for the "PBS News Hour." Short break. We'll be right back.

REHMAnd welcome back. We're talking about the rollout of the Affordable Care Act, not only the number of people who signed up, but the expectations, what people think is provided and questions that they may have. Here's an email from Allison in Fulton, Md. She says, "I enrolled my family of four in Maryland for the ACA. I ran into issues with the MD website but found I could go straight to the insurance provider website to enroll.

REHM"Are there any estimates on how many others may have purchased insurance direct from health insurance companies to avoid the troubled websites? If others did the same, there may be an undercount in the number enrolled." Julie?

APPLEBYYes, that's partly why we don't know exactly how many people have enrolled because people could go to insurers and directly purchase coverage. For the most part, those were people who didn't qualify for a subsidy because it was only just in the last few weeks that some insurers under a pilot testing were allowed to actually help through the process...

REHMI see.

APPLEBY...of doing the subsidy eligible enrollment. And in some of the press calls they had with us in December, they were saying that that pilot was going well. They were hoping to expand it to more insurers. I believe Florida Blue in Florida is one of the insurers that are doing this directly, and that is one way people can sign up for coverage if they want to bypass healthcare.gov.

REHMHere is another email from Melania who says, "I signed up for the ACA for my husband, toddler and myself. We could only afford a high-deductible, low premium plan, even with the subsidy. I assume this meant catastrophic coverage because I had to pay out of pocket till I reached the deductible before the insurance will cover. So, with this type of coverage, is my family still eligible for free preventive exams and visits?" Susan?

DENTZERYes. It sounds as if the caller, or the emailer signed up for probably a bronze level plan, possibly a silver plan. These plans do have deductibles that are higher on average than is the case in typical employer provided insurance.

REHMWhat about catastrophic coverage?

DENTZERWell, that doesn't -- it's not clear that that's what the person has. You know, catastrophic coverage doesn't have an official definition, but often the deductibles are very high, $10,000 as opposed to $2,500, for example. So, assuming that this person got something closer to a bronze level plan with a deductible in the neighborhood of $2,500 or so, nonetheless, preventive services are covered at no co-pay to the insured.

REHMOK. Let's go back to the phones. Let's go to Michael in Lithia, Fla. Hi there. You're on the air.

MICHAELYes. Hi. Speaking on behalf of Michael, I just wanted to ask, so what happens if, like, you, your past taxes were much higher than the, like, the 2013 taxes are much lower than the 2012? So, when you're trying to apply, do you, are they going to check your tax returns based on the 2012, or do I have to wait until April till the 2013 come out?

APPLEBYSo it sounds like the key issue here is that your income or Michael's income is fluctuating year to year. Is that correct?

MICHAELYeah. Exactly. Yep.

APPLEBYSo the -- what in effect will happen is that a preliminary estimation will be made about -- you are required to stipulate what you think your income is likely to be in 2014. And you can use some of the past information of what your income has been in the past.

MICHAELOK.

APPLEBYThat the adjustment will come at the end of the year. And, of course, that will be next year, so it will not be until April of 2015 that there would be any particular adjustment in the subsidy underpayment/overpayment or what have you.

MICHAELOh, gotcha. So when they -- OK, so when they ask, like, what's your average income, you just put an estimate of what you believe that you're going to make on 2014.

APPLEBYYes. Yes. And there's additional -- there will checking against your previous income to make sure that that is likely to be in the ballpark.

MICHAELGotcha. OK.

REHMOK.

MICHAELIt's the same thing as -- is everything the same in the country? 'Cause, say, California, what we're looking at, I know California had its own, like, website separate than the Obamacare. I just want to make sure that it all applies to the entire country.

APPLEBYYes. Yes.

REHMAll right. Thanks for calling. And let's go to Ali in Wheaton, Maryland. You're on the air.

ALIHi, actually, it's Ali.

REHMAli. Hi.

ALII'm just calling. My husband and I are both self-employed. My husband's a green card holder. I tried to enroll immediately in October, and it was just a terrible, terrible mess. Finally, in December, I was able to get through. We picked a plan. We got a reference number. It says you're enrolled. This was before the 20th of December. And since then, I assumed I'd be getting something in the mail as I normally do when I enroll in insurance and got nothing. And so we haven't paid a premium. Now I'm terribly concerned we're not covered. Is that the case?

APPLEBYYou may well not be covered. You need to make sure you pay that premium. What the CMS folks were telling us earlier this week is that people who haven't received a bill or any kind of a welcome letter from their insurers should call that insurer and try to talk with them and find out what's going on. They've also said that if you are unable to resolve it through them, you need to call the healthcare.gov number, and they will help you resolve it as well. But, yes, people are not enrolled until they pay that first month's premium.

DENTZERThere's helpful information on the healthcare.gov website about the tips for using your new insurance coverage which also has a number that you can call at the marketplace call center as well.

ALIThank you.

REHMAll right. You're welcome. To Eric in Fenwick Island, Del. Hi there. You're on the air.

ERICHi. Thank you for taking my call.

REHMSure.

ERICI wanted to respond to one of your panelists who earlier stated that a lot of the effects of the ACA were going on behind the scenes and out of view of the public, particularly in terms of readmission for chronic conditions like CHF. I'm a paramedic down here, and rather than seeing decreases in these patient populations, we're actually getting a lot more who will tell us that I was discharged on Tuesday, and now I'm sick again.

ERICAnd I'm concerned that, rather than incentivizing proper and longer term care inpatient, what we're actually seeing is an incentivization of people being held longer in emergency departments. So the person who comes back in a week later with congestive heart failure is being held in the ER for another 12, 14 hours until they can get things under control and discharge them again. And that might be accounting for decreases in hospital admissions. It's not actually decreasing patients' treatment rates.

APPLEBYThat's quite possible. If you don't stay in a hospital for 24 hours, it's not considered an admission. You're still an outpatient.

REHMYeah. Yeah.

APPLEBYSo if you're in the ER, you're never actually admitted.

REHMRight. OK, Eric, thanks for that input. And to Hugh in Moultrie, Ga. Hi there.

HUGHDiane, I can't believe I'm on national radio here, but I thank you. I just wanted to address the roar of patient census in hospitals. One of the things that we face is, in particular in the state of Georgia, the battle about allowing specialties to get certificate of needs to open ambulatory surgical clinics, taking traditional patients, such as urology patients, ophthalmic patients, and even nephrology patients out of a hospital.

HUGHAnd one of the challenges is is because patients going there that normally would have been treated in a hospital providing the capacity of hospitals to give indigent care to people because we have the profits to do that with. One of the things affecting hospital census is that most of these one-day surgeries are surgeries that do not require hospitalization overnight are going to these clinics and therefore are not required to be in the hospital. And it's really becoming a challenge to us rural hospitals here, but we are attempting to address these poor rural populations, Diane.

REHMSusan.

DENTZERThis is one of the many important set of impacts not just of the Affordable Care Act but of the changing way we're delivering healthcare in the country. And as we try to move care out of hospitals -- because that is, of course, the most costly form of healthcare -- and keep people either healthy in the community or even do what you're doing, trying to address needs in a rural context, we're going to see declines in hospital use.

DENTZERHow we handle that remains a major national challenge because, as you say, typically, hospitals have cross-subsidized a lot of care of the indigent and others by offering certain services that are now gravitating out of the hospital. So it is a challenge.

DENTZERPersonally, I think we probably are going to need some kind of a federal program to support hospitals, critical access and other hospitals to make the transition to provide alternative forms of care in this country that is not inpatient based and hospital based because we're still going to need a healthy core of institutions providing health in the community, just not necessarily the old way of putting people into inpatient beds.

REHMAll right. Question from Pensacola, Fla. Hi Marty.

MARTYHi, Diane. I really appreciate your intelligent and civil discussion you have on your show.

REHMThank you.

MARTYI just wanted to share my story. I get tired of people complaining about the Affordable Care Act and, you know, these people saying it's going to lead to the end of civilization as we know it. My wife and I, we're paying $3,200 a month for insurance. I'm an independent business person. I own my own business. And we were paying $3,200 a month because she contracted cancer about five years ago. And we didn't have any place else to go. And so they kept increasing our premiums, increasing our premiums every renewal.

MARTYAnd with the preexisting condition, we didn't have a choice. But I went on the healthcare.gov website, early part of November, and printed out the 14 different plans that were available, the 14 different platinum plans that were available in the state of Florida, and studied those, went to our local Blue Cross/Blue Shield insurance office, which is who we had our $3,200 a month coverage through, picked the best platinum plan that they had for us, and we decreased our premium from 3200 a month to $1700 a month for better coverage.

MARTYSo I don't really understand what the problem is. And I'm in a state where our governor, our Republican governor, has totally resisted the implementation of the Affordable Care Act.

REHMYeah. That's a very interesting story. Let me just remind you, you are listening to "The Diane Rehm Show." Marty seems to have done a very thorough job at examining what was available and coming up with a cost reduction in his plan, something that would serve him and his wife very well.

DENTZEROne of the real difficulties about the Affordable Care Act is that, because it's a complex law laid on top of a very complex system, is that almost everything you could say about the law is true for some group of people. So, for some very significant group of people, such as yourself, premiums went down, not just down but way down.

REHMSignificantly.

DENTZERSignificantly down. And mainly because of the -- now the evolution to a system where we're not going to charge people more because they're already sick or have a preexisting condition as your wife clearly did with her cancer, so an enormous amount of benefit for an enormous number of people from that provision. There are other people who are paying more under the law, and that's a function of other changes in the law.

DENTZERIt's also a function of the complexities of the existing insurance market in various states and the variation in insurance coverage even within states. So it's gratifying to hear that at least one part of this story is certainly true in your own instance, as it's going to be true for many people across the country, but others will experience different effects.

REHMAnd one more caller in Chevy Chase, Md. Hi John.

JOHNHi, Diane. Thanks. Great to be on your show.

REHMSure.

JOHNWhen I first spoke to your person, I had one impression. But as the show has gone on, I'm gratified to see that for the first time, it seems that people are actually talking about how people are benefiting from the Affordable Care Act instead of riding on other peoples' journalism, talking about snafus.

REHMYeah. I think we all got a little tired of hearing about the snafus and not enough about what the good parts are. Now, Julie, I know you've written recently about some aspects of the Affordable Care Act you wanted to share.

APPLEBYYes. I think the gentleman makes a very good point. John makes a very good point that the media has focused a lot on the problems, but there's been a lot of problems. I mean, the rollout was a disaster. So that got focused on. But now we're going to start hearing more of these stories. It's going to become almost sort of a battle of the anecdotes. There'll be different concerns that are raised. In the past, under the old system, I've written a lot of stories about people who were rejected for coverage, like some of your callers, because they had cancer or another condition.

APPLEBYWe're not writing those stories anymore because that's no longer allowed. But there's going to be other concerns. Some people are not going to like the deductibles. They're going to be higher than they are used to. There's going to be some narrow networks where -- meaning, will their doctor be in the plan? We'll be doing stories about that. There's going to be other issues as well.

APPLEBYBut the deductible issue is an important one. It's something that your caller mentioned, and, for many people, the bronze and silver plans have two or three, $4,000 deductibles, many of which need to be met before much care is covered.

APPLEBYWe did a piece just recently looking at bronze plans in seven different cities around the country, and we had E-Health Insurance help us with the analysis. We found that about half of the bronze plans don't pay anything towards your doctor visits until you meet that deductible, except for preventive care, so that's something people will also be talking about. We're hearing stories about that as well.

REHMOK. And I think we've got to do one last question, and that is about the exit of Jeff Zients and his successor. Very briefly, Susan.

DENTZERWell, it was very clear all along that someone was going to have to take over when Mr. Zients went back to the job he was supposed to have, which was running the National Economic Council. And now we have a gentleman from Microsoft who's been brought in to oversee that. We imagine he's going to be there for a while, because, of course, even though open enrollment period will end on March 31, we have to start getting ready for open enrollment next year.

REHMSusan Dentzer of the Robert Wood Johnson Foundation, on-air analyst on health issues for the "PBS News Hour," Julie Appleby, senior correspondent with Kaiser Health News, thank you both so much.

DENTZERGreat to be with you, Diane.

APPLEBYThank you.

REHMAnd Happy New Year to all. I'm Diane Rehm.