Guests

  • Margot Sanger-Katz Correspondent at The New York Times. She covers healthcare for "The Upshot".
  • Julie Rovner Senior correspondent, Kaiser Health News; author of "Health Care Policy and Politics A-Z."
  • 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."

Maps: Who Was Helped Most By The Affordable Care Act?

New York Times reporter Margot Sanger-Katz took a look at coverage under the Affordable Care Act across the country in a series of maps that give a closer look at who has benefited (or not) from the law.

Obama's Health Law: Who Was Helped Most

Transcript

  • 10:06:53

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. It's been more than a year since the rocky rollout of the Affordable Care Act and the number of uninsured Americans has fallen about 25 percent. But those numbers are just one part of the story. The law has raised a host of concerns from changing premiums to difficulties finding a doctor.

  • 10:07:20

    MS. DIANE REHMJoining me to talk about how the Affordable Care Act is performing so far, Julie Rovner of Kaiser Health News, Ceci Connolly of PWC's Health Research Institute and Margot Sanger-Katz of the New York Times. Throughout the hour, we'll invite your calls, your questions, your calls and comments are always an important part of the program. Call us on 800-433-8850. Send an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. And thank you all for joining us.

  • 10:08:04

    MS. JULIE ROVNERNice to be here.

  • 10:08:05

    MS. CECI CONNOLLYNice to be here.

  • 10:08:06

    MS. MARGOT SANGER-KATZThanks.

  • 10:08:06

    REHMGood to see you. Margot, let's start with the numbers. How many who were previously uninsured are now insured because of the ACA?

  • 10:08:21

    SANGER-KATZSo there are a couple of different estimates for that.

  • 10:08:23

    REHMAll right. We're having a little problem, Margot, with your microphone. Let's try that again.

  • 10:08:32

    SANGER-KATZSure. So...

  • 10:08:34

    REHMNope. Not working. Why don't you take it, Ceci?

  • 10:08:39

    CONNOLLYSure. I think part of what Margot was pointing out there is that so far there are a number of surveys. We don't have the definitive count done by the census, typically. HHS has put out some numbers saying that about 10.3 million previously uninsured now have health insurance. The other estimates are in that vicinity as well, between 8 and 11 million.

  • 10:09:03

    REHMSo put that in perspective. What's the overall U.S. picture, Ceci?

  • 10:09:09

    CONNOLLYWe have gone from approximately 20.3 percent uninsured of the population, down to around 15 percent in approximately one year's time, which is a pretty significant decrease when you think about that. Unfortunately, we will continue to have uninsured in this country. There are some that will be ineligible for coverage, primarily undocumented immigrants.

  • 10:09:37

    CONNOLLYAnd then, as we all know, there's still a big target group out there of uninsured who everyone is hoping to enroll. So that's the status today.

  • 10:09:51

    REHMSo Julie, how does that stack up against expectations?

  • 10:09:51

    ROVNERIt's actually a little exceeded expectations. Now, of course, you know, some of this got more complicated when the Supreme Court ruled in 2012 that states did not have to expand Medicaid. So now, what you have in -- now, it's a little bit less than half the states, about 23 states, people who are not eligible for anything, who were anticipated to be eligible for Medicaid when the law passed.

  • 10:10:13

    ROVNERSo you've got this Medicaid gap, people who are under 100 percent of poverty, but who have -- and therefore, are not eligible to be in the exchanges, but earn too much to get Medicaid in those states or in the cases of adults who don't have children, some of those people are not eligible at all, no matter how poor they are. So you've got a big chunk of people in that Medicaid gap and then you have, as we mentioned, people who, you know, simply, as Ceci said, don't actually get on.

  • 10:10:41

    ROVNERAnd that's one of the targets for this year. You've got sort of a complication, which is that you need everybody who signed up last year to reenroll and then you need to start picking up more of these people who haven't enrolled yet, but are eligible.

  • 10:10:54

    REHMSo what groups have we specifically reached now, Ceci?

  • 10:11:02

    CONNOLLYWell, it's interesting. One of the pleasant surprises in the first year is that there's been a fair amount of success reaching young adults. And that has typically been one of our larger uninsured groups in this country and through a combination of allowing them to stay on their parents plans up to age 26, that was a very quick, early victory from the law, as well as getting many to enroll via the exchanges last year, there's been a great deal of progress with respect to the young.

  • 10:11:36

    CONNOLLYOther groups that have benefitted so far from the availability of health insurance would be African Americans and Hispanics, two groups that typically have had higher rates of uninsurance. There's also -- I think this is a little bit more anecdotal and maybe I just know more of these folks, but you have the people who are pre-retiree age so they're not yet 65 and eligible for Medicare, but maybe they've lost a job or changed jobs or have temporary jobs.

  • 10:12:05

    CONNOLLYAnd you hear a lot of anecdotes from those individuals about finally being able to purchase insurance.

  • 10:12:10

    REHMAnd Margot, what about people and access to doctors? What's happened there?

  • 10:12:19

    SANGER-KATZI think it's a little bit early to say, but what we can see from some early surveys is that people who have gotten new coverage, they are saying that they're able to get doctors in a reasonable amount of time. But certainly, especially with the explosion of enrollment in Medicaid programs, I think there are valid concerns that there may be difficulty for those new beneficiaries in finding doctors.

  • 10:12:39

    REHMAnd Ceci, what about affordability? That was central to the law.

  • 10:12:46

    CONNOLLYWell, the key to answering that question, Diane, is to start by saying that more than 80 percent, almost 85 percent of the people that enrolled via those exchanges, qualified for some subsidy. And the subsidies were very powerful inducements and are really the reason why so many individuals are able to purchase and afford the health insurance.

  • 10:13:09

    CONNOLLYWe've been crunching the numbers for 2015 at our health research institute and right now, we have, with 41 states and the District of Columbia, reporting an average monthly premium across the board, all plans, of $381, but that is pre-subsidy. In most instances, that 80 to 85 percent of the shoppers will pay significantly less than that.

  • 10:13:35

    REHMNow, isn't that the issue that's before the Supreme Court and whether the court is going to decide to take that on?

  • 10:13:45

    CONNOLLYYes, potentially. There have been a few challenges that have been coming up through the state courts and one is now before the Supreme Court. They took no action on this this morning, which means they could still indicate whether they want to hear the challenge to the subsidies.

  • 10:14:03

    REHMGo ahead, Julie.

  • 10:14:04

    ROVNERYeah, this is -- everybody was sort of waiting because they took this up for the first time Friday afternoon at their conference. It was sort of expected that they wouldn't take it or deny it this morning. Typically, these cases come up a couple of times at -- these are the private conferences that the justices have.

  • 10:14:20

    REHMSo what's the next time it could come up?

  • 10:14:23

    ROVNERNext week. We could hear about it again next week.

  • 10:14:24

    REHMOh, I see, I see.

  • 10:14:26

    ROVNERBut most people expect that the court would not take it. At this point, what we have is the appeal from the fourth circuit in Virginia where the appeals court decided that Congress intended -- what happened was there's a vague line in the law that says that you can only -- that subsidies are only available in exchanges established by a state.

  • 10:14:51

    REHMFour words.

  • 10:14:52

    ROVNERFour words, established by a state. So what the plaintiffs, the people who are suing are arguing is that that means that you can't get subsidies in any of the federal exchanges or in the federal exchange. That's 36 states so most states are operating under the federal exchange. What they're saying is that the subsidies are illegal. What the people who wrote the law said is that's not what we meant.

  • 10:15:15

    ROVNERIf you look at the law in its entirety, it's pretty obvious that we intended subsidies to be available whether it was a state exchange or a federal exchange. That's what the fourth circuit found. Now, in D.C., it gets more complicated. There was a circuit court that found the other way, that, you know, that's what the law said. That's what Congress must've meant. But the full circuit court in the District of Columbia vacated that ruling and is hearing it on bank and that hearing won't even be until December.

  • 10:15:41

    ROVNERAnd then, we have a third case coming up through Oklahoma that hasn't been to the appeals court yet. So right now, there's, technically, no split in the circuits. All there is is this fourth circuit decision and it would be not unprecedented, but most people think extremely unlikely for the court to take it, unless and until there is an official split in the circuits.

  • 10:16:00

    REHMMargot, do you want to add to that?

  • 10:16:03

    SANGER-KATZYeah, I think that this may become before the court at some time, but it's pretty unlikely to happen now and it's because there are these other cases in other parts of the country. The Supreme Court generally likes to get involved when there's a disagreement among different circuit courts. That hasn't really happened yet.

  • 10:16:17

    REHMWe were talking about affordability. The question is, do people feel that this ACA is, indeed, affordable, Margot?

  • 10:16:31

    SANGER-KATZI think it really depends on who you are. So we've seen, you know, Medicaid is a program that, in states that expanded it, you can qualify for it without paying any premiums at all and you have to pay very little in the way of copayments or any kind of out-of-pocket dollars if you go seek medical treatment. So for those people, certainly, it is quite affordable and it's made medical care potentially more affordable for them.

  • 10:16:51

    SANGER-KATZAnd then, if you look at the way that the subsidies to help people buy their health insurance are distributed, at the lower end of the income spectrum, people who are earning, say, you know, $25,000 a year for an individual person, the subsidies are pretty generous and make those premiums quite low. But for people who are higher on the income scale, especially people who don't qualify for subsides, the premiums can be pretty expensive and then, on top of that, a lot of these plans have a lot of cost-sharing.

  • 10:17:19

    SANGER-KATZThey may have high deductibles and they may also limit the doctors and hospitals that are covered so, you know, you may go to a doctor and end up getting a very big bill, even though you thought you had health insurance.

  • 10:17:31

    ROVNERI think a lot of the people that we heard about last year who are sort of unhappy with the affordability had two things going on. One of them is that if they were in the individual market before -- and remember, we're talking mostly about the individual market. It's a small percentage of people in the individual market. Most people still have insurance through an employer or through Medicare or Medicaid.

  • 10:17:51

    ROVNERBut for these people, if they were in it before, it means almost by definition that they were healthy because you were screened out if you were sick. So now, under the law, sick people are allowed in also so the premiums tend to be higher. So for the people who were in insurance before, many of them are paying more and are yelling about it.

  • 10:18:09

    REHMJulie Rovner of Kaiser Health News. When we come back, we'll talk further, take your calls. I look forward to speaking with you.

  • 10:19:39

    REHMAnd welcome back. We're talking about the Affordable Care Act today with Ceci Connolly. She's managing director and leader of PwC's Health Research Institute. She's co-author of "Landmark: The Inside Story of America's New Health Care Law and What It Means for Us All." Margot Sanger-Katz is correspondent at the New York Times. She covers health care for "The Upshot." And Julie Rovner, senior correspondent for Kaiser Health News, author of "Health Care Policy and Politics A - Z."

  • 10:20:25

    REHMAnd speaking of politics, here's an email from Thomas who says, "It's not perfect but why are Democrats not claiming more credit with the populace successes of the ACA such as coverage for the young, preexisting conditions, etcetera," Ceci?

  • 10:20:49

    CONNOLLYWell, our research is not focused on politics but I think by looking at other surveys that have been conducted, we know that at the moment this is an unpopular president. And the law is most often referred to as Obamacare, so I think some people here that name and have a negative reaction. At the same time, the surveys that ask questions about some of those specific items that you mentioned are...

  • 10:21:15

    REHM...preexisting conditions, carrying a child to 26.

  • 10:21:19

    CONNOLLYAbsolutely -- are very, very popular. So you might have a little bit of reaction to an unpopular leader. But on the substance elements that people like I would also just say that there are many, many, many Americans that are not necessarily touched by this law in any way. They have, as Julie pointed out, employer-sponsored health insurance. This was mainly a bill for the uninsured. And so you have a lot of people that aren't directly experiencing it.

  • 10:21:50

    REHMJulie.

  • 10:21:51

    ROVNEROne of the interesting things about this election is that Republicans are not using the law as much as, I think, many people expected it would be a big issue. And it's not. It's very much a side issue. And, in fact, one of the interesting things you've seen in Kentucky where Senator Rich McConnell is in a tight race to hang onto his seat and if he thinks he's lucky he will become majority leader. He said because the law has been so successful in Kentucky, they have a Democratic governor, he was saying, well, even if we repeal the law, you could keep the website, which of course many of these fact-checking organizations said, yeah, not really. It's not quite how it works.

  • 10:22:26

    ROVNERBut, you know, you had Republicans in some of these interesting situations. And we have to repeal the law but we're going to keep this, this, this and this because, as Ceci pointed out the component pieces of the law tend to be popular, the law itself, not so much.

  • 10:22:39

    REHMMargot.

  • 10:22:39

    SANGER-KATZYeah, you can really see the heat kind of coming off this issue in this election if you compare it to what we've seen in the last two cycles. But it is true, if you look at the public opinion polling, this law remains pretty deeply unpopular. And there hasn't been a lot of movement in that, you know, through the last few years when we've been having this debate. And I think the real key to that is what Ceci pointed out. Most Americans, their lives are not really going to be improved by this law. This law is primarily a law that is going to provide coverage to people who had difficulty accessing it before. And I think in general, people are worried about changes that might harm them and that aren't going to help them.

  • 10:23:11

    REHMHere's an email from Angela in Cleveland, Ohio. She says, I don't know all the policy and politics involved with the ACA. All I know is it's greatly benefitted people like me. I work three part-time jobs. None of them offers health insurance. I am one of the working poor who for years had no health insurance because it was too expensive for me to buy. Having health insurance now allows me to have the security that if something were to happen, I have coverage," Ceci.

  • 10:23:52

    CONNOLLYAnd that was clearly the intent of the law, Diane, is to reach the individuals like Angela who through circumstances have a tough economic road to hoe. And this does give them some peace of mind and security, no doubt about it. I think the challenge for the Angela's of the world out there this fall is they've got to look at the options again for next year. And they've got to really do some pretty smart shopping because the plan that Angela's in right now may not be her best option next year. So unfortunately, more hard work for a lot of those people.

  • 10:24:31

    REHMSo what about people who don't speak English? What about people who don't have computers, how will they manage this transition that begins November 15, Margot?

  • 10:24:46

    SANGER-KATZSo there are a lot of organizations out there on the ground that have sort of in person assistors who can help you, who will speak your language, who will provide you with a computer and answer questions. And what we saw from last year is that even though there's been a lot of discussion about the website, I mean, the idea this was going to be like an Amazon.com for health care. Actually people really did want a lot of hand-holding and assistance because buying insurance is really complicated. Most people don't understand what any of the terms means. For a lot of people this is the first time they've ever purchased a health insurance plan.

  • 10:25:15

    SANGER-KATZAnd so it's clear that enrollment is going to depend a lot on the assistance of these people who are experts and who are kind of shopping assistance for individuals.

  • 10:25:24

    ROVNERI think there's two big problems. One of them is that this enrollment period is only half as long as last year's. The first year it was six months. Now it's just three months.

  • 10:25:32

    SANGER-KATZAnd it's during the Holidays too.

  • 10:25:33

    ROVNERThat's -- and I was going to say, it is during the Holidays when people are distracted by other things. Plus...

  • 10:25:39

    REHMBut it also may give them a little more time in the sense that they've got a period that's off work that may allow them more time to...

  • 10:25:50

    ROVNERThat's true. That's true. And it's right in the middle this time. And Medicare used to come up to the end. Medicare, actually the open season ends even earlier. But one of the other big problems as I alluded to is that if you're already in a plan, it's important to go back through the process because the good news is that there's going to be more competition next year. There are going to be many more -- some of the big companies are either expanding or joining the exchanges for the first time. But the bad news about that is that it has changed which plan the subsidies are based on.

  • 10:26:18

    ROVNERSo even if your plan doesn't change, your subsidy might be dramatically different. So it really is important to go back in and look at all the plans and how much they would cost and what kind of subsidy you're eligible for.

  • 10:26:31

    REHMGive me an example of why a subsidy might change.

  • 10:26:36

    ROVNERThe subsidy is tied to what -- the second lowest costs over plan. So if you're in a county or a metropolitan area where that was $300 a month, now the second lowest -- because there's so much more competition, it may be tied to a plan that's only $200 a month. So if you weren't in that plan, your subsidy was based on that price. It could go up or go down depending on where you are.

  • 10:27:01

    REHMSo you're going to have to do some careful research all over again, Ceci.

  • 10:27:07

    CONNOLLYYou are, unfortunately. I mean, we hope that more of those online calculators will help people as they sort of plug in some of their information and help deal with that math. Or as Margot was pointing out, there are so many navigators and assistors out there, different organizations that are really trying to walk people through the process.

  • 10:27:26

    CONNOLLYI mean, I often suggest to folks that get all of your information organized. It's almost a little bit like when it's tax season. You pull all your information together there at the dining room table and you've got it all laid out. You know, how much money you make at your different jobs. You've got to add it up, how many family members you're going to cover. What are their ages? Think about what doctors are really important for you to see because you have a relationship with them maybe. And when you've pulled all of that information together then you can really start shopping.

  • 10:27:56

    REHMMargot.

  • 10:27:57

    SANGER-KATZSo I did an analysis with a colleague a couple of weeks ago looking at filings from some of the states that published their insurance rates early. And what we found is that there's just a tremendous difference between staying in the plan that you were in before and shopping for a new plan. So we looked at the plan that was the most popular one last year in each market. And for people who just renewed those plans, they were looking at an average increase of over 8 percent. And for people who shop for the cheapest plan in that same category, it was more like a 1 percent increase.

  • 10:28:26

    REHMSo they've got to look carefully at what they have and what they could have before they choose.

  • 10:28:36

    SANGER-KATZAbsolutely, yeah.

  • 10:28:37

    ROVNERThe other thing that I think people will probably be looking at more this year, it's not just premium but some of these other out-of-pocket costs. And there have been -- there's been a lot of sticker shock that say, yeah, I have a premium that's $20 a month but I have to spent $6300 out of pocket in order to get -- you know, before even -- in some cases before coverage starts in some of the bronze plans. So it may be that people need to look at the cost sharing also and decide, maybe I want to spend 10 or 15 or $20 a month more to get a lower deductible before I have that coverage.

  • 10:29:08

    SANGER-KATZAnd the final consideration has to do with doctors. So, you know, you may be attracted to a low premium plan but all of your doctors are in one that's a little more. And so I think for individual people they have to weigh those things. Maybe it's worth, you know, 10 or 20 or $30 more a month to know that you can go to a hospital where you have relationships with the physicians.

  • 10:29:26

    REHMHow do the increases that may or may not come up in the Affordable Care Act compare with the increases we're likely to see in those employers insured plans, Ceci?

  • 10:29:42

    CONNOLLYWell, Diane, that's one of the things that is striking to me is that again, right now our map is showing about a 6 percent average premium increase. And that is right in line with what we are seeing in the employer-sponsored marketplace. Now, there are many of us that think that that is too high, especially when GDP is rising at much, much smaller rates. I mean...

  • 10:30:07

    REHMAnd especially since annual increases in salary are rising at smaller rates.

  • 10:30:14

    ROVNERAnd part of the reason for that, Diane, in so many instances is because employers are saying, you've got a choice. Either we keep contributing this amount to your health insurance but not much of a raise for you. You want a bigger raise you're not going to get as much in health insurance benefits. I mean, this is sort of the full picture that employers look at when they are thinking through your complete compensation package. And so, you know, what dawns on me is I think that affordability is going to be the next big health care debate in this country, not just for the individuals on the exchanges but for all of us who are looking at those 6 and 7 percent increases and we're not happy about what we're getting for that money.

  • 10:30:57

    CONNOLLYAnd, you know, I think a lot of these increases have been kind of ameliorated by putting more of this, what we were just talking about, more cost sharing onto people. You're having to pay more for your drugs. You've having to pay more when you go to the doctor. You're having to pay more when you go to the hospital. You're having higher deductibles in general. That's happening not just in these exchange plans. That's also happening in the employer market. So people -- it's sort of this creeping -- you know, people are paying larger and larger shares of their bills.

  • 10:31:20

    CONNOLLYNow there are economists and other people who think that's a good thing that when people have, you know, quote unquote "skin" in the game, they'll be better shoppers. The hard part of that is that it's still incredibly difficult to shop according to price in the health care market.

  • 10:31:33

    REHMAnd what about Medicaid? How is that fitting in to this whole picture, Margot?

  • 10:31:42

    SANGER-KATZSo it appears that Medicaid is going to make up more than half of all the new enrollments that we've seen in the last year. So it's really a huge part of the Affordable Care Act's expansion of coverage to people who didn't have it before. And that's somewhat by design but I think the high numbers is a little bit higher than some of the forecasters had said.

  • 10:31:59

    SANGER-KATZAnd, you know, Medicaid is a very rich benefit. It covers a lot of services. So for those people, they have very comprehensive benefit but the difficulty with Medicaid sometimes is that it doesn't pay doctors very well in a lot of states. And so doctors often don't want to see those patients. And so I think there's a concern that there are a lot of people now who have any insurance card. They may not be able to use it very effectively.

  • 10:32:20

    REHMAnd you're listening to "The Diane Rehm Show." Julie, are we expecting more and more states to come in on that Medicaid benefit?

  • 10:32:33

    ROVNERYes, and they have been. I think there's a lot of people who expect eventually we'll probably see all of the states, the way we did when Medicaid started in 1965. It wasn't until 1982 that Arizona came in. They were the last state to join. But we're seeing, you know, Republicans, even some very conservative Republican governors, you know, now discovering, often at the behest of their hospitals. Because one of the tradeoffs for Medicaid was that one of the ways to pay for the law, they were going to pay hospitals who serve large numbers of uninsured people less on the theory that well, there will be fewer numbers of uninsured people because they will all have Medicaid.

  • 10:33:08

    ROVNERWhat's happened in these states that haven't taken the Medicaid expansion is that the hospitals are losing the money but they're not -- these people don't have Medicaid so they're in serious trouble. And we've seen a lot of pressure from a lot of these hospitals and hospital systems on some of these governors who have been hold-outs. And these are pretty much all Republican governors.

  • 10:33:26

    REHMCeci.

  • 10:33:27

    CONNOLLYDiane, this is real money for the hospitals. We've been crunching the quarterly earnings reports. And the hospitals -- you can see the health systems in the states that have done the Medicaid expansion versus not. The financial results are dramatically different. And so right now the Medicaid expansion has been a boon for many hospitals, just by looking at their financial numbers. Admissions are up. Their uncompensated care typically through the emergency department has come down.

  • 10:34:01

    CONNOLLYSo you are seeing that occur. And in fact, we've got 26 states plus the District of Columbia that have expanded so far. Four more states, I believe, are doing what's called a waiver. They're using the Medicaid money to do something a little creative or different. And then our estimate is at least six more states will be in play next year.

  • 10:34:22

    REHMTell me, Margot, about the cancellation issue. What's happened there?

  • 10:34:28

    SANGER-KATZSo the law said that every insurance plan that was sold on the individual market starting in this year had to meet certain minimum characteristics, had to cover a certain array of services. You couldn't have a health plan that say didn't cover hospital benefits or didn't cover drug coverage. And then it also had to cover a minimum percentage of what your expected bills were going to be. And there were a lot of plans that were being sold on the individual market before that just didn't meet all of those rules.

  • 10:34:54

    SANGER-KATZAnd some of them were a little bit specific. Like there was a rule that maternity and prenatal coverage had to be included in a benefit. And maybe some single people like single men, they didn't want to buy a plan like that before. So what happened is if you had been continuously enrolled in the same plan for this whole period, you were allowed to continue to renew it. But if you had been in a plan for a shorter period of time, then you were no longer able to continue it and you were expected to buy a new plan that, you know, fit in with all of these new rules.

  • 10:35:22

    SANGER-KATZAnd it was a big story. I'm sure you all remember last year when the first round of cancellation notices went out right around the same time that the exchange website was having so many difficulties. And so the administration gave states the opportunity to sort of put off those cancellations. And now some more are starting to come out.

  • 10:35:39

    SANGER-KATZSo some people who had health plans that they like now will not be able to stay in them. And they'll either have to choose a different plan on the exchange or even off of the exchange. But this is sort of an issue that is sort of going away slowly because there really aren't a lot of people left in these kinds of plans. And what we know historically is that people who are in the individual market don't tend to stay there that long. They're usually people who are maybe between jobs or whose income has shifted around. And so some people are going to have their plans cancelled this year, but not as many as last year. And there will be fewer of them next year.

  • 10:36:13

    REHMCeci, you mentioned hospitals and crunching the numbers there. What about the health care industry as a whole? How has it fared?

  • 10:36:26

    CONNOLLYWell, by and large so far pretty well under this law. I mean, one measure is the S&P 500 health care index. It's up about 24 percent over a year ago. We see 56 new issuers competing on the exchanges in 2015. By our account the number is doubling in at least four states. Most of the publically-reported health care companies, insurance, pharma, etcetera continue to have strong financials.

  • 10:36:58

    REHMCeci Connolly. She is managing director and leader of PwC's Health Research Institute. Short break here, then your calls when we come back.

  • 10:39:38

    REHMAnd welcome back. Time to open the phone, take your calls, comments, questions on the Affordable Care Act. Let's go first to Dallas, Texas. Hi there, Paul. You're on the air.

  • 10:39:55

    PAULThanks for taking my call.

  • 10:39:56

    REHMSure.

  • 10:39:56

    PAULI've got a couple of quick anecdotes and I'll be as brief as possible.

  • 10:39:59

    REHMOkay.

  • 10:40:00

    PAULI'm self employed and the insurance I was carrying doubled from $650 a month to $1,200 a month as soon as the ACA took effect. And I wasn't going to follow along with that just on general principle, let alone the economics of it. So I went shopping. And we don't have a state marketplace here, so I went straight to the insurance company and was able to get vastly better coverage, although it was at $250 more a month than my previous premium. But I appreciate the coverage and I was actually able to take advantage of the preexisting condition clause. So, you know, Democrats would call that a victory. Republicans would call that a failure. But I call it a wash, but I'm happy to have the coverage.

  • 10:40:39

    PAULNow, I'm self employed and I sell durable goods to businesses, both large and small. And my industry has been in turmoil ever since the 2008 presidential election. And first, it was because people -- businesses didn't know how to spend money because of taxing. And then when the ACA started coming around, they didn't know how they were going to have to pay insurance. So they didn't know about buying durable goods. Well, just as things started to calm down, you know, a year later, now they're predicting that the Republicans are going to take the Senate and they've got an axe to grind on the ACA. So we're starting to tighten our belts again and get ready for the businesses not knowing how to spend money.

  • 10:41:15

    PAULAnd that's scary to me. And I say this all to you as a Texas conservative. And then, you know, I'm just kind of ready for things to calm down.

  • 10:41:22

    REHMAll right. Thanks for your call. Margot, that sort of fits right in with this email from Kay in Dayton, Ohio, who says, "If Republicans win a majority in the U.S. Senate, maintain a majority in the House, what are the possibilities for them to roll back the ACA?

  • 10:41:46

    SANGER-KATZSo certainly Republicans in the Senate and in the House as well, you know, tend to oppose the ACA. Many of them have campaigns just aversely against it. But what they can actually do in the way of completely repealing the laws is really limited. They just don't have the votes. And even if they did have the votes, the president would almost certainly veto any full-scale repeal of the law.

  • 10:42:06

    REHMJulie.

  • 10:42:07

    ROVNERAnd they don't, you know, there's a lot of talk -- well, could they use the budget reconciliation process, which only requires, you know, 50 votes in the Senate or 51 votes in the Senate? They could, but there's two problems there. One is that not all of the law is allowed to be addressed under that process. And the other one, as Margot says, is the president can veto it. Nobody is suspecting that the Republicans -- there's not enough seats up for the Republicans to get enough to override a veto.

  • 10:42:33

    REHMSo Paul has both a plus and a minus reaction to the ACA, Ceci.

  • 10:42:41

    CONNOLLYYes. And I also think that we don't know enough about all of his personal circumstances, age and family, and Texas is a difficult market right now. It has not expanded Medicaid, for instance. It continues to have a very high number of uninsured. So there's probably still more of that cost shifting going on in that state than potentially some others where you have many, many, many more people in the risk pools. You know, it's interesting though. I certainly agree with both Julie and Margot in terms of what could happen in a Republican-led Congress in the next two years.

  • 10:43:20

    CONNOLLYI do think it's worth mentioning, however, that there are a few provisions that could be in jeopardy. I'm thinking, for instance, about the medical-device tax because we see bipartisan opposition to that. And a president in his lame-duck final two years may need to be doing a little bit of give-and-take in those circumstances. Another thing that I certainly am keeping an eye on are the level of those subsidies. They're quite expensive. They go up to 400 percent of the federal poverty level. And there could be a very serious discussion around whether or not that comes down.

  • 10:43:56

    REHMAll right. Let's go to Barbara in Indianapolis. Hi, there. You're on the air, Barbara.

  • 10:44:03

    BARBARAHi, Diane. Yes, thank you for taking my call.

  • 10:44:05

    REHMSurely.

  • 10:44:06

    BARBARAI have two points that I'd like to make. I am a health-care provider in Indianapolis. I work with people who have had cancer and are currently going through cancer treatment. And two things for the last year have really struck me. One is the number of people who had full-time jobs and who are struggling through their cancer treatment or the aftermath of their cancer treatment with a full-time job and have health insurance.

  • 10:44:32

    BARBARAAnd as a result of the Affordable Care Act, lost their full-time jobs, went to part-time so their employers did not have to cover them and have not been able to find affordable care under what's available with their part-time job, but in Indiana, being above a threshold for having some assistance, possibly because of a spouse or some other situation like that and having huge deductibles that they just can't possibly meet. And yet they're required to have monthly visits. And so that really -- those are both of my questions. One is, what are we going to do about all of these people who have lost full-time jobs as a result of the ACA?

  • 10:45:11

    REHMSure. All right. And, Julie.

  • 10:45:14

    ROVNERWell, the administration and others have looked at this sort of every conceivable way. And it looks like the number of people who have been moved from full-time to part-time because of the law seems to be not that big. I mean that -- this is something that we keep hearing about and hearing about and hearing about.

  • 10:45:29

    REHMWho's telling us about that?

  • 10:45:31

    ROVNERPeople who oppose the law, largely. And there have been some anecdotal situations where that's happened. One of the things that Ceci didn't mention that I will about -- that they could take a new look at, is whether this question of 30 -- having a 30-hour week, that's the threshold for which employers have to provide insurance -- whether that's too low and that they might want to go back to 40 hours to prevent this from happening. But the issue of very high deductibles we've all talked about. And I should point out, we're seeing this not just in exchange plans. We're seeing this in employer plans. It used to be that $1,000 deductible was very unusual and now it's the norm. So...

  • 10:46:06

    CONNOLLYIt's 42 percent by last count that -- 42 percent of the people getting their health insurance through their employer have a deductible of $1,000 or more. So again, this is an industry trend that people are starting to wake up to.

  • 10:46:22

    REHMAll right. Let's go back to the phones to Julia in Baltimore, Md. Hi, there.

  • 10:46:30

    JULIAHi. How are you this morning?

  • 10:46:31

    REHMI'm good.

  • 10:46:33

    JULIAMy question-comment type thing is, I thought all the years I was working, I was paying into future Medicare, from the deductions on my wages. I became eligible for Medicate and applied. I retired. I didn't have insurance at that job. But I thought that I would be covered by Medicate. I got a visit from an insurance company who told me I had to buy -- positively had to buy my other insurance coverage and that they were taking over supplying my Medicare.

  • 10:47:24

    REHMJulia, I think you may have gotten some inaccurate information. Margot.

  • 10:47:32

    SANGER-KATZSure. So as long as you worked a minimum number of years, you would be eligible for Medicare.

  • 10:47:36

    REHMLet me ask, how many years did you work? Julia.

  • 10:47:40

    JULIAI've been working since I was 18. I retired when I was 72.

  • 10:47:45

    REHMOkay. Sounds to me as though somebody's trying to pull a funny one.

  • 10:47:50

    SANGER-KATZI think someone's trying to sell her what's called a Medicare Advantage policy.

  • 10:47:53

    REHMYeah.

  • 10:47:53

    SANGER-KATZNow you are -- the thing about Medicare is everybody loves it. Unlike the ACA, it's really popular. On the other hand, Medicare also exposes its beneficiaries to very large cost sharing. You have to pay 20 percent of your doctor bills. The first-day hospital deductible is way up over $1,000 now. So there's -- and there are, for Part B, there are premiums. So you have a choice. You can get what's called a Medigap policy, a private policy that will help you with the cost sharing. Or you can go into Medicare Advantage, which is a managed-care plan that basically takes over all of your health care. They get paid by Medicare and then they provide you with your coverage. So those are basically your options.

  • 10:48:31

    REHMBut she does not have to do one of those things, does she?

  • 10:48:36

    SANGER-KATZNo, she doesn't. But most people -- most people have one or the other. Sometimes, when you retire, you have wrap-around Medigap coverage...

  • 10:48:42

    REHMSure.

  • 10:48:42

    SANGER-KATZ...that your employer provides. So they help with that. If you're low-income, you get help either through Medicaid -- there's some programs for people slightly above Medicaid. So there are lots of different ways to help fill in the gaps that Medicare has.

  • 10:48:54

    REHMSo it depends on her own individual situation.

  • 10:48:58

    SANGER-KATZSure. And how much coverage she'd like to have. I would certainly encourage Julia and other retirees out there -- you can either go to the government website, medicare.gov. They also have toll-free telephone numbers. And there are plenty of organizations, such as AARP, where you can really get some straight, factual information and guidance.

  • 10:49:17

    REHMGood.

  • 10:49:18

    CONNOLLYAnd we should point out, we're in the midst of the -- the ACA open season doesn't start, but we're already in the middle of the Medicare open season, which started the middle of October, goes through the beginning of December. So this would be a good time, if she wants to investigate her options.

  • 10:49:30

    REHMGood.

  • 10:49:31

    CONNOLLYShe's in the period in which she can change.

  • 10:49:33

    REHMBut don't be pressured by some salesperson who walks in the door.

  • 10:49:39

    SANGER-KATZNo, certainly not. If she wants to have a traditional Medicare policy, she can get that. She's eligible for it.

  • 10:49:46

    REHMAnd a tweet from several listeners about a comment I made. Enrollment during the holidays doesn't mean more time. Part-time workers tend to work more seasonal hours, not less. So, I apologize. Let's go now to Louisville, Ky. Hi, Barbara. You're on the air.

  • 10:50:13

    BARBARAGood morning, Diane.

  • 10:50:14

    REHMHi.

  • 10:50:14

    BARBARAThe statement that I have, and then I have a question.

  • 10:50:18

    REHMSure.

  • 10:50:18

    BARBARAMy son works in Louisville and at the end of last school year, his employer dropped their insurance. He and -- he was expecting a baby at that time, so he was looking into getting on the -- or the Kentucky Connect insurance. They moved to Indiana and everything turned upside-down. He fought to get insurance for himself. And then he has tried for four months -- the baby is now four months old -- to get the baby on his policy. They went in the other day for a four-month checkup. The baby has been ill with a cold for over a month. They went in for the four-month checkup to get the babies shots and was told that the pediatrician would not even see the baby because they would not accept the insurance that my son was told would cover the baby.

  • 10:51:22

    BARBARANo one seems to be able to talk to him to make any sense out of where he needs to go to get answers to get this child covered.

  • 10:51:30

    REHMWell, let's see if we can help. Margot.

  • 10:51:34

    SANGER-KATZSo, you may remember that last year there were all kinds of problems with the healthcare.gov website...

  • 10:51:40

    BARBARARight.

  • 10:51:40

    SANGER-KATZ...that was helping people sign up for health insurance. And a lot of those problems have been fixed. Bu the particular kind of problem that it sounds like your son is having is one of the problems that persists, which is, there's still not very good communication between the federal government and the health insurers. So they're not sharing information back and forth about who has what plans. And it makes it much harder, if your circumstances change during the year, to say, okay, I no longer live in Kentucky, I now live in Indiana. Or I now have a new child in my family. Or I got divorced. Or I lost my job. And so these are problems that people are experiencing as they have these kinds of life changes.

  • 10:52:14

    REHMSo what can this young man do? Julie.

  • 10:52:18

    ROVNERWell, certainly, it's not clear whether he -- where he got the new insurance -- whether he got it -- it would be in Indiana and the federal exchange, but he can, you know, he should really go back to the insurer or go back to whoever helped him purchase the policy. If that was the federal government, there's a helpline there. If that was -- if he went through a private insurance broker, he could go back -- he could go back and do that.

  • 10:52:39

    REHMAnd you're listening to "The Diane Rehm Show." I sure hope that helps. Let's go now to -- if I can get this curser working -- to Dave in Clearwater, Fla. Hi, there.

  • 10:52:55

    DAVEGood morning, ladies. Thanks for taking my call. I'm going to be as brief as I can...

  • 10:52:58

    REHMOkay.

  • 10:52:59

    DAVE...because I have a million questions. But...

  • 10:53:00

    REHMHow about one?

  • 10:53:02

    DAVEOkay. Sounds good. I'm looking for specific data, if it exists, comparing apples-to-apples. Specifically, for the folks who were insured through the individual marketplace already, before the law -- how are they faring afterwards? Because I know -- it's my understanding that most people get subsidies of some sort.

  • 10:53:20

    REHMAll right. Ceci.

  • 10:53:21

    CONNOLLYOh, Dave. That is my great wish. I wish that we could do the apples-to-apples comparison. But the simple fact is that the markets are so dramatically different. If you think back to before the law, the individual health insurance market, they could deny people coverage entirely, with preexisting conditions. They could charge ten times as much for one person to another, depending on their health status. There was not much transparency. And it was a very small group of individuals getting that insurance. Today, everybody has the ability to get coverage. They've limited the -- they're called rating bands, to three.

  • 10:53:59

    CONNOLLYSo you also have limits on the amount of profits, essentially, that health insurers can now make under this new law. So unfortunately, it is apples-to-oranges.

  • 10:54:10

    REHMInteresting. All right. To Cynthia in Houston, Texas.

  • 10:54:16

    CYNTHIAHello.

  • 10:54:16

    REHMHi, Cynthia. You're on the air.

  • 10:54:18

    CYNTHIAHi, there. I have a question about group-provided -- excuse me, employer-provided group plans and how the Affordable Care Act affected those. I don't have direct experience because I was already on Medicare. But I'm hearing stories from friends that their group plans provided by their employers, the premiums went way up and the benefits went way down. And this is all because of Obamacare. Is that true?

  • 10:54:50

    ROVNERNot directly. There is -- I mean, I think a lot of -- as we've been talking about, there has been this trend towards higher deductibles, asking employees...

  • 10:54:59

    CYNTHIARight.

  • 10:54:59

    ROVNER...to pay more. There is what's called the head tax and that's one of the ways that the law is paid for. But it's, I think, $64 a year. So I mean, that -- so it's -- you know, and I was actually on the benefits committee of my former employer, so I, you know, I saw how this impacted. I think it was like a half of a percent. So if the average in increase is 6 percent, yes there are -- and there are some plans that were not providing enough coverage. But it's not -- this is not required -- this is not the cause of benefits going down. But simply we were seeing -- you know, I've been thinking about this a lot lately -- what would the insurance landscape look like in the absence of the ACA?

  • 10:55:37

    JULIAClearly, costs would have continued to go up, employers would have continued to ask employees to pay more.

  • 10:55:42

    REHMAnd here is the final email from Sam. "Where is the Democratic messaging about the ACA this time around? I am hearing nothing." Margot?

  • 10:55:56

    SANGER-KATZIt's true. The Democrats have not been talking very much about this law. We've seen a couple of examples of candidates who have talked about the benefits of the law. And particularly, they talk about, you know, the bar on preexisting condition, bans on things like that. But in general, the Democrats have not found this to be a particularly helpful political issue. And they're not talking about it too much.

  • 10:56:16

    REHMMargot Sanger-Katz, she's correspondent at The New York Times. Ceci Connolly of PwC's Health Research Institute. Julie Rovner, senior correspondent at Kaiser Health News. Certainly a complicated issue. I hope this morning has helped folks. Thank you all so much.

  • 10:56:42

    SANGER-KATZThank you.

  • 10:56:42

    ROVNERThanks.

  • 10:56:42

    CONNOLLYThank you.

  • 10:56:42

    REHMAnd thanks for listening. I'm Diane Rehm.

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