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The new enrollment season for health insurance under the Affordable Care Act has begun. The health care law has led to millions of newly insured Americans, but an estimated 10.5 million who are eligible for coverage remain uninsured. The Obama administration has been encouraging more people to sign up, but expectations are modest even though penalties for not having insurance will increase in 2016. Many premiums are expected to rise as well, making shopping for the right plan even more important. Join Diane and a panel of experts who talk about navigating the third enrollment phase of the Affordable Care Act.
- Mary Agnes Carey Partnerships editor and senior correspondent, Kaiser Health News
- 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"
- Louise Radnofsky Health policy reporter, The Wall Street Journal
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. If you don't have insurance through your employer, it's time to log onto Healthcare.gov or one of the programs that some states offer under the Affordable Care Act. Your premium might be higher in 2016. That's why it's important to comparison shop, even if you've already enrolled. A panel of healthcare experts joins me to talk about the new open enrollment season and answer your questions.
MS. DIANE REHMHere with me, Mary Agnes Carey of Kaiser Health News and Louise Radnofsky of The Wall Street Journal. Joining us from an NPR studio in New York, Ceci Connolly of PwC's Health Research Institute. I know many of you will have questions. Do join us, 800-433-8850. Send your email to email@example.com. Follow us on Facebook or Twitter. Thank you all for being with us.
MS. MARY AGNES CAREYIt's great to be here.
MS. LOUISE RADNOFSKYThanks for having us.
MS. CECI CONNOLLYGreat to be here.
REHMMary Agnes, I'll start with you. It's the beginning of round three. Give us a sense of the picture now.
CAREYWell, as you say, it's the third year for open enrollment for the Affordable Care Act. The federal exchanges opened shop on November 1, which was Sunday. State exchanges opened around the same period of time. And so whether it's a state exchange or the federal exchange, officials are trying to reach a group that have, so far, said no to them in the first two open enrollment periods.
CAREYThe Department of Health and Human Services says there are about 10.5 million people out there eligible for the exchanges. Many of them are confused about how they work. They don't know there's assistance to help them enroll. If you live in a state that does not like the Affordable Care Act, perhaps one of the southern states, you might not have heard much about it or heard negative things about it. And HHS has set a goal to enroll of that 10.5 million, one in four.
CAREYSo they have a very aggressive outreach campaign to these folks, advertising on the radio, advertising on television, lots of in-person sister events throughout the country to help people get greater understanding and figure out if this is going to work for them.
REHMCeci Connolly, there have been a lot of hiccups along the way. How well prepared are we this time to enroll a much greater number?
CONNOLLYWell, you're correct. There have been hiccups, especially, we all recall fall of 2014 when, my goodness gracious, they just couldn't seem to keep that website up and running at all and that really slowed progress that whole first year. I think that clearly many of those technical glitches have improved. One of the issues that we've heard more recently this time around is that it's still challenging to do nice comparison shopping, kind of the easy apples to apples, let me stack up a couple of my options here, that that's still a little bit of a challenge.
CONNOLLYAnd it's very important for consumers trying to make sense of what, under the best of circumstances, is a complicated decision for anyone.
REHMLouise, when you think of those comparisons that people are going to have to make, what are the most efficient ways to go about doing that?
RADNOFSKYWell, it's a tough year for a number of consumers, especially given that there are fairly significant premium increases in some part of the country for the people who are in the most popular plans. So they're going to affect a large number of Americans who get their coverage through healthcare.gov or a state site. The Obama administration, in particular, is emphasizing the availability of subsidies to help people offset the cost of premiums.
RADNOFSKYWhat we're hearing from some state regulators is that they want people to consider more than just the premium. They want them to consider the deductible as well. In particular, the network that might be available to them, all the kind of factors that people need to bear in mind when they are buying health insurance.
REHMBut as Ceci said, it's hard to compare. So what's the best way to go about doing that?
RADNOFSKYIt's hard to compare and sometimes there aren't great options for people. One of the things that we're starting to see is that where there's been a big premium spike, for example, there may not be a cheaper plan available that would result in somebody paying less money in 2016 than they were in 2015. There is, possibly, a plan that would allow them to spend less in 2016 than they would've if they stayed with their big plan, but that's a challenge for the consumers.
RADNOFSKYAnd, of course, it's a challenge for people who want to keep people enrolled as well.
REHMSo Mary Agnes, if you're already enrolled, if you already have your insurance, does it make sense to go back to what you have and sort of start all over again in comparisons?
CAREYIt absolutely does. It makes sense to go back to Healthcare.gov. Let's say you're on a federal exchange plan you purchased because the federal government runs the exchange in your state. You can see what you currently have. You can also see what's out there. You can sort it from last expensive to most expensive. You can look at what are the deductibles. What are the copays? Like Louise is talking about, we've got to remember it's not just the premium.
CAREYIt's all of that out-of-pocket stuff, the copay at the doctor, the coinsurance, the deductible. When does my plan kick in? You might find that your plan maybe isn't offered again. Perhaps it is. You might find a better option. You might decide to go -- we have these metal levels, gold, silver...
RADNOFSKYThank you. Platinum, silver, bronze, gold and silver. You might decide you want a different plan. If you get a bronze plan, your premium might be less, but your out-of-pocket might be more. There's all sorts of variables to think about.
CONNOLLYDiane, just to underscore how important and valuable it is for consumers to do this shopping this time around, we know that the silver level is the most popular plan out there and that's the one that's really drawing the significant numbers. People in 2015 who shopped around for silver, so they were in it in 2014, they shopped in 2015 and in many cases, they switched plans, those folks that switched plans in 2015 saved about $33 a month or $400 for the year.
CONNOLLYActually, saved. But they switched plans and that's what's so tough because inertia, you know, most of us in an employer-sponsored plan, we probably just check the box and say, sure, give me the same one as last year. We might only have two choices. So in some respects, a choice can make it challenging for these folks in the individual market, but that shopping can really bring them savings.
REHMAll right. Here is an email from John in Grass Lake, Michigan. And I do want to try to get in as many callers, as many consumers as possible. John says, "My wife and I have used the exchange to buy our health insurance the last two years. It's been great. We kept our doctors and specialists and our deductible went down $9,000 annually. But last week, we were told our policy is no longer available in our county. What does the county we live in have to do with our insurance policy? Our doctors are spread over four counties. We use three different hospitals in three counties." Mary Agnes.
CAREYWell, welcome to the mystery and complexity of health insurance.
CAREYYou've got to remember that premiums vary not only from state to state, but within a state and within counties. And there's no requirement that a health insurer offer one plan from one year to the next. And so what's happening to this consumer is something that can happen in the market. This is a market-run system. These are private insurances companies making their own decision. So who knows what happened? Did they have too many beneficiaries that were too costly in that area?
CAREYDid they -- the providers, the hospitals and doctors and so on, could they not negotiate the prices they wanted with those providers so they're leaving? Did they just decide we want out of this area of the country and we're gone?
REHMYou know, it makes you wonder whether the Affordable Care Act can be trusted. Louise.
RADNOFSKYWell, we've certainly seen from major insurers who entered into the Affordable Care Act's exchanges in the first couple of years that they're committed to staying there more or less for the time being, but those exchanges haven't given the business opportunity that people perhaps expected they would be. It hasn’t been a gigantic windfall for health plans and they're already looking, in some ways, to other avenues of business, such as Medicare advantage instead.
CONNOLLYWell, I don't know that it's been a windfall, but in many cases, these health plans have picked up new customers who they're starting to learn a lot more about. Don't forget, if you're in the health insurance business, the name of the game is to get a sense of the health status of your population and then do a better job of keeping them healthy. If you keep them healthier and manage their conditions, you're not going to have those big, giant costs.
CONNOLLYThat takes time. We are seeing expansion in a number of places around the country. Think about -- I'm here in New York with the famous start-up, Oscar Health, which is very technology-driven. They're moving into two gigantic states this year, California and Texas. So you can see around the country that there are companies that are still seeing opportunity and pursuing that, but it's a mixed bag.
REHMCeci Connolly, she's managing director and leader of PwC's Health Research Institute and co-author of "Landmark: The Inside Story of America's New Healthcare Law And What It Means For Us All." Here in the studio, Louise Radnofsky, health policy reporter for The Wall Street Journal and Mary Agnes Carey, partnerships editor, senior correspondent for Kaiser Health News.
REHMWe do invite your questions, comments. Join us on 800-433-8850. Send your email to firstname.lastname@example.org.
REHMAnd we're talking about the third round of enrollment in the Affordable Care Act. Mary Agnes Carey, this has a deadline of December 15, is that correct?
CAREYIf you'd like your coverage to start January 1, your deadline is December 15. You could actually enroll until the end of January, if you like, but you've got to remember that 15th of the month is critical to start the following month. So, again, January 1, enroll by December 15.
RADNOFSKYIt's also an important date for you to change your coverage for the year ahead if you want to. The federal government is going to automatically renew plans for most people who don't come back to healthcare.gov to shop around. And many of the states are following suit.
REHMAll right. We have two emails from Texas. And I gather that's one of the states that did not take the ACA, is that correct? All right. One from Timothy in San Antonio, Texas, who says, my platinum plan in two years has risen 60, 6-0, percent. And a tweet from Devlin, who says, several of my friends who enrolled under ACA in Texas will have 33 percent higher premiums in 2016. Is this due to lack of state support? Ceci.
CONNOLLYWell, the issue around state support -- or let's call it enthusiasm -- is that it's been difficult to reach a number of folks and to get them the information they need and to assist them with this enrollment process, which is so challenging. So those are all hurdles in a number of states around the country, including Texas.
CONNOLLYWith respect to those premium increases, a little bit of context -- and this comes back to our earlier discussion about really shopping -- so Health and Human Services reported that over the past year the second lowest-cost silver plan rose about 7.5 percent. We did an analysis looking at the three-year period for those silver benchmark plans and found that from 2014 up until this new enrollment, they rose an annual -- they rose a percentage of 4.4 percent. Now that's much more in line with those of us that are getting our health insurance in the employer-sponsored market. And so there -- it is possible to find these better deals. It just takes some hunting.
REHMHmm. Go ahead, Mary Agnes.
CAREYTo the person in the platinum plan, again, that's the top of the middle tier. That's the Cadillac plan, very generous plan. What I would recommend is that he think about the -- how much he's paying in a premium, that those plans tend to be more expensive premiums but lower out-of-pocket costs. Maybe a silver plan, Ceci's talking about, would work. Maybe a different silver plan, a bronze plan, a gold plan -- that's right below platinum. There are all sorts of options. Get on healthcare.gov and just take a look. You might find something that works.
REHMOkay. Is this going to happen each and every year? That you're going to have to see how your own plan's working and get on dot gov to find out whether your plan's going to increase and whether you ought to change, Louise?
RADNOFSKYYes. But 2016 is a particularly bad year.
RADNOFSKYThat's the year that people are looking ahead. Because for health insurers, they didn't really know what their market had been like heading into 2015, because they didn't have a lot of data and because the launch of healthcare.gov had sort of sent some confusing signals. Now they do know and they say they've adjusted their prices accordingly. They're also, in some ways, looking at prescription drug prices and other factors. But this is the year that we've really seen a big change. And optimists are hoping that it's a one-off readjustment period, although we don't yet know that, obviously.
REHMAll right. Here's an email from Maria, who says, we have health insurance for my family of five via the Maryland exchange. We were notified our plan was being cancelled. We would be reenrolled in the most similar plan available. This meant our premiums would be increased by more than 20 percent and our deductible and co-pays would go up, too. As I look for a new plan on the exchange, I feel all the plans have gone up in price. Why? This seems especially true for the silver plans. Is that so, Mary Agnes?
CAREYWell, the silver plans have gone up. Ceci mentioned the second lowest-cost silver plan, they call the benchmark, that's what the subsidy is tied to. Those are predicted to increase 7.5 percent next year. For 2015, that increase was about 3 percent. So you do see an increase. And again, I think, as Louise is pointing out and Ceci has done as well, insurers are trying to figure out, who are these people that we're insuring? Obviously, for the first year of enrollment, I think some of the sickest people came in. They're expensive. That may begin to even out a little bit. But insurers are trying to adjust this to make sure it works for them. But when this happens, the consumer is the one caught in the middle, like the two folks we just talked about.
REHMDid any of the insurers have their rate hikes -- their request for rate hikes denied by state regulators? Louise.
RADNOFSKYIn a few instances, state regulators were able to tamp down proposed increases. But I think the shocking story for 2016, a surprise for a number of people, was that contrary to expectations, state regulators green-lighted increases of 36.3 percent in Tennessee, for example, or 25 percent in Oregon. They said they didn't like them but they understood why the insurers were asking for them. They were, in regulator language, justified. And they wanted to make sure that the plans stayed solvent as well. And so they had to allow them for the sake of consumers, however concerned they were and motivated to keep premiums down, because they actually supported the Affordable Care Act, in Oregon's case.
CONNOLLYOne thing I would just add, especially for a consumer perspective, and that's why percentage increases are important and worth taking a look at. In the end, it all comes down to dollars and cents. So let's take, for instance, Minnesota, which this year is looking at increases in their premium rates of about 29 percent. That's a whopper percentage. And yet, compared to most of the United States, Minnesota continues to have some of the cheapest plans available on the market.
CONNOLLYThe lowest -- second-lowest cost silver plan in Minnesota, I believe, is about $235 a month. And that, of course, is before a subsidy. And the vast majority of these exchange customers are shopping with subsidies. So they have to do that extra calculation. But again, to them, it really comes down to dollars and cents.
REHMAll right. And what about penalties for those who do not get the insurance, Louise?
RADNOFSKYWell, they're going up to their maximum this year. The penalty starts at $695 for an individual. It can go up to nearly 2.5 percent of income. So it's certainly very high and that is expected to act as one push factor. That said, for people who are looking at premiums of $235 a month and they're not sure if they can afford that, the penalty is still cheaper. And this is still a prospect that they may be weighing.
CAREYAnd of those two factors, remember, it's whichever is greater -- $695 or 2.5 percent of income, whichever is greater. People miss that. For the first year, it was $95 or 1 percent of income, whichever is greater. People had in their heads, 95 bucks? And then they didn't get insurance and they went to file their taxes. And their tax preparer, or maybe they saw it online themselves, said 1 percent of your income is the greater number. That's what you pay. And that's all above that filing threshold, which is about $10,000.
REHMSo it's either, if you have your health insurance through your employer, or you have one of these plans and are covered, and if you have neither, then...
CAREYIf you don't have -- if you can quality for -- so there are some exemptions. There are some hardship exemptions based on income and other factors. But unless you qualify for an exemption, if you don't have coverage, this is called the individual mandate, the requirement that most Americans have insurance or pay this fine.
REHMGive me some of the exceptions.
CAREYYou could be homeless. You could be incarcerated. The premium could be, I want to say something like more than 10 percent of your income. There are a variety of things that are there, they're on healthcare.gov if you want the full list. But they're fairly extensive. Some people say they're fairly generous. Many, many people could fall into them, it depends. But it's important to look, if you think -- if you're looking at that fine and it's prohibitively expensive for you, you need to look at the exceptions list and see if you can get one.
REHMAll right. I'm going to open the phones, 800-433-8850. First, to Chagrin Falls, Ohio. Jan, you're on the air.
JANYes, hello. Thank you for taking my call.
JANMy son will be 26 in March of 2016, which means he no longer will qualify under our insurance coverage. As his parents, we can no longer cover him. When should he apply for a plan under Obamacare?
CAREYLet's go over that again. He turns 26 when? This year. Okay.
JANIn March of 2016.
CAREYMarch of 2016, okay. I would be getting on -- you could look on the exchanges now. He would qualify for a special exemption to open enrollment because he doesn't hit 26 until next March.
CAREYBut just for informational purposes and to prepare yourself, I would get on an look. He also could apply for something -- they're calling it a young, invincible plan. It's a catastrophic plan. It's for people under 30 and people that meet some other circumstances. But I would get a sense of it, get a feel of it, look what's out there, so he has time to see, is his doctor on this plan? Do they cover any prescriptions he might take? Go ahead and take a peek. But he will qualify for a special exemption to the enrollment period. And again, this is information you can find on healthcare.gov. And you're in Ohio, so you're on the federal exchange.
REHMHope that helps. Thanks for calling. To Michael in Dallas, Texas, you're on the air.
MICHAELHi, Diane. Good morning, for hosting this program. I just want to say that those people that are trying to kill this program are not well-intentioned Americans. I never had insurance before. I was able to buy one last year for $164 for me and my wife. And the deductible is kind of high, but there's a company I found online called deductmeble, D-U-C-T-M-E-B-L-E. It says, it's membership -- my membership, I pay $44 a month. And if I go to the hospital or doctor's office, whatever my deductible or coinsurance is, they will pay it for me. I just send the bill over to them. They pay it for me. Everybody is happy.
CONNOLLYI'm not familiar with that specific company. But one of the things we have tracked at our Health Research Institute is that the Affordable Care Act has actually sparked quite a lot of entrepreneurship across the country. We counted up about 100 brand-new companies that have been formed directly out of this law. Many of them are startups. Many of them are using technology even, for instance, think about on your mobile phone now, the health care, not only information but even telemedicine. You can have a consult with a clinician on your mobile phone today in many, many states under many circumstances. So there is a lot of this creative entrepreneurship that has been sparked. And that might help us find a path to more affordable healthcare.
CAREYI think that that's a great example of somebody who has benefited from health insurance. They're obviously using the subsidy. It's a low premium, sounds like, they're getting. They may qualify for some of the assistance in the law that helps you with all these out-of-pocket costs, the co-pays and the deductibles. For some folks, this is working. But we've just heard so far, today, about people who are looking at a plan they really like and it's not there anymore or the premium is jumping up in price. It's all over the map and that adds to the complication of this law. It can mean different things for different people in different parts of the country.
REHMIs there any plan to revoke this law? Is that still in the wind?
CAREYWell, politically, of course, you know, the Republican candidates for the presidency don't like the Affordable Care Act. There are many members of Congress on the Republican side that still hate it. I want to say we've had north of 50 hearings to repeal the law and different pieces of legislation and votes on the House floor and some in the Senate as well. The problem will be, even if Republicans were to run the White House and keep control of Congress and they want to repeal the health law, what do you replace it with? By that point, you will have millions of people, Medicaid coverage, coverage with the exchanges, the Affordable Care Act is woven into the fabric. What do you do?
REHMAnd you're listening to "The Diane Rehm Show." Let's go now to Tulsa, Okla. Curtis, you're on the air. Go right ahead.
CURTISOh, yes. Hello. Yeah, I was calling, I was curious about, my family, we do a health sharing plan, where each month we look at a newsletter that's sent to us and send our premium directly to another family. And vise versa, when we have a need, we'll receive multiple checks from other families. And since the Affordable Care Act has gone into effect, an enrollment in our particular plan has seen their highest enrollments almost every month. And I guess I was just curious if, with some of the premiums going up and some of the troubles the website has had, if any of your guests were aware if types of plans like health-sharing plans -- ours is through a nonprofit -- if those types of plans are becoming a greater portion of the market?
RADNOFSKYI've certainly heard a lot more about them in the last couple of years. We first -- they were first on a lot of people's radar, I think, when the health law was being passed and the exemption to the individual mandate did include a provision specifically to address people who are members of these health care sharing ministries. They're usually Christian affiliated an they're usually based on a Biblical principle of sharing. And they come with certain restrictions as to what they'll cover and as to what members have to do. They're not insurance. But people who are in them speak about them very enthusiastically.
RADNOFSKYAnd again, the volume of that enthusiasm has gone up, including among people who have been uninsured but wanted to consider their other options. People who are uninsured do need to get health care somehow. And when I talk to them, I'm always struck by the creative ways in which they find to do that. This is one of them. And perhaps, since I -- one of the least creative ways in doing it, it's so established at this point.
REHMBut I'm not sure I understand. Do they fall under the ACA?
RADNOFSKYNo. Essentially, members agree to pay each other's bills. And so far, they appear to have been able to do that. They're not insurance. I don't think any state insurance regulator would consider them to be the equivalent of a health plan. But again, they're popular with people who use them.
REHMSo are they going to get fined or not?
RADNOFSKYNo. They -- if you have -- if you're a member of a health care sharing ministry, you are not subject to the individual mandate -- or, rather, you've fulfilled your obligations under the individual mandate, as far as the federal government is concerned.
REHMAnd how do people find these particular kinds of plans?
RADNOFSKYUsually because the people who talk about them are very enthusiastic about them. It's word of mouth. But they're also on the Internet. I think Medi-Share is a popular one.
REHMThat's very interesting. And usually, as you say, a religious community somehow affiliated with some kind of religious organization?
RADNOFSKYI've never seen a non-Christian one, but they may be out there.
REHMInteresting. All right. We'll take a short break here. And when we come back, we'll take as many of your calls, your email as we can, to answer your questions about the Affordable Care Act. You have until December 15 to enroll, in order to be covered beginning January 2016.
REHMWelcome back. If you've just joined us, we've got a panel of really well-informed people on the program, talking about the third round of enrollment in the Affordable Care Act. And if you've enrolled by December 15, you will be covered starting January 1. If you wait a little longer, you'll lose one month because you could enroll as late as January 31, but you will have lost that month. Mary Agnes Carey is with me. She's with Kaiser Health News. Louise Radnofsky with the Wall Street Journal. And via ISDN and Skype from New York City, Ceci Connolly of PwC's Health Research Institute. Lots of folks from Texas writing in, calling. Here's one from Jan. Can you talk a little about the benefits, potential risks and cost to the consumer in working with a health insurance broker?
CAREYIt's a great idea to go to someone that you know and understand, whether it's a broker or an agent, to sit down and to help navigate this field. I mean, you can go on healthcare.gov. Some people find it intuitive, and they understand it, and they find it easy, but others may not. And I think somebody with that landscape can help you sit down and walk you through it, talk you through it, and that in-person assistance is so important.
REHMHow much is that going to cost?
CAREYIt probably depends on what that agent does, but I would think in many cases, maybe in some cases they get some money from the plan itself. I don't know exactly what the terms would be between the broker and the health plan. They may charge some type of fee. You'd have to figure that out with whoever you sit down with. But I think the bigger takeaway is that this in-person assistance is extremely helpful for people.
REHMAll right, here's an email from Joe, who says he's currently enrolled in a health care plan through one of the co-ops, the Kentucky Health Care Cooperative. They recently announced they will not be operating next year. There are 10 co-ops across the country that have now ended their service. What are your guests thoughts about the end of the member-owned co-ops on the affordable overall state of the Affordable Health Care Act? Ceci?
CONNOLLYWell, it's unfortunate in a number of states because some of those co-ops were becoming popular as nonprofit alternatives to some of the insurance companies around the country. It certainly illustrates that health insurance and health care is still very complicated in the United States today, and we knew that this was going to be a testing period for the first few years. I think one thing to point out, and we've certainly heard this in the case of the Kentucky co-op and several others, a number of insurers were expecting to receive risk corridor payments this year from HHS.
CONNOLLYThese were essentially monies to help smooth out the extremes for health companies. So for instance if you were a health plan that had very expensive beneficiaries, and it cost you a lot of money, you even lost a lot of money, you'd be expecting money, well, from the federal government. In the end, what happened was that the federal government said it only has 12 percent of the money that it thought it was going to have to give you.
CONNOLLYSo stop and think about running a business or running your own personal finances, imagine if someone said to you, next week I'm going to give you $100, and next week rolled around, and they gave you $12. How would you feel about that, and would that affect your budget? In some cases it's been a very big hit for some of these. Others, some of the larger insurance companies are able to manage this better. I do want to point out, though, that even in Kentucky, you still have nine additional silver plans to choose from and three new carriers in Kentucky this year. So there's still a good bit of competition out there.
REHMBut are those silver plans going to be a lot more expensive than this co-op that she was part of?
CONNOLLYWell, it is possible, but again you don't want to be in a health plan that prices so low that it doesn't have the money to cover the health care costs of its members. That's the whole challenge in health insurance is having enough money to pay out all those claims. So you've got to strike that balance.
REHMAll right, let's take a call from Weatherford, Texas. Kevin, you're on the air.
KEVINYes, good morning, thank you. I'll give you a little background on my situation. My wife is a public schoolteacher. She is offered health insurance. But for our two daughters and me, the premium is either $950 or up to $1,250 a month. And on her $37,000 a year salary, that's a problem. I was laid off a few months ago. I believe I am not, or we are not, able to get subsidies in the marketplace. Do you know if that's correct?
CAREYHere's the test. Is the policy that she is offered at work deemed to be affordable and credible in the sense of coverages? And so here's another difficulty with this is there's a percentage, and I want to say it's about nine -- if the price of the premium is nine percent of your income, if it's not more than nine percent of your income, and we're talking about the price of the premium for an individual plan, not a family plan.
CAREYThis is determining affordability, right. So what happens is if you were go on healthcare.gov or sit down with an assistor or a broker or an agent, they would sit down and look at the price that you're quoting me, they would look at her income, they would run the calculation, but again that percentage, which I think is nine and a half percent of income, is based on the price of the individual plan that she's offered for individual coverage, not for family coverage. That's the affordability test. And if that's the case, then you would not get subsidies for coverage, but her income is kind of low, so I'm having this thought that maybe you might qualify. Have you tried? I don't know if you've gone to healthcare.gov and done any of those calculations. They'll prompt you on how to do it.
KEVINWell, initially it's showing we would not be eligible.
KEVINAnd then that turns into my original question. It almost appears that if her and I were divorced, and I went to the marketplace and got coverage for myself and my daughters, our daughters, then I would get the subsidies she could use for her employer health care, or health insurance provider, and it would all work.
CAREYWell, I certainly don't want you to get divorced.
CAREYBut I have to say this wouldn't be the first time that in federal law, and I might want my colleagues to jump in here, I want to say in some of the Medicaid issues in the past, you've had couples making this kind of inquiry decision to get coverage for their child based on income.
CAREYI'd like to open it up.
RADNOFSKYThere's also a factor in the school district's decision to make coverage available to spouses and other dependents that is having an impact. This phenomenon has a name. It's called the family glitch. And it certainly does hit people in circumstances similar to this, where the offer of coverage is affordable technically under the law for the individual but not for the rest of the family. It arose because of the way the law was drafted, the way it was interpreted by federal agencies and the inability of the administration, essentially, to find the money to pay for fixing it or to get such a fix through Congress. So it could persist for a while.
RADNOFSKYThe children may be eligible for state children's health insurance coverage, depending on the family's income. It's pretty tough in Texas, and it certainly won't include the father, but it may be worth looking into it for the kids.
REHMCeci, do you want to jump in?
CONNOLLYNo, I was just going to point out the same with respect to the children, and this is certainly a trend we are seeing in the employer-based market, where essentially companies may be willing to offer their worker decent health insurance coverage, but they are really jacking up the prices if you want to add on a spouse and children to your plan.
REHMOkay, so let's talk about options for Kevin. I mean, this is terrible that he is actually thinking he may have to get a divorce in order to have either himself alone or himself and his children covered. Does he have to get a divorce?
CAREYWell, no, another way to look at this, it isn't ideal because you'd like to have the entire family on the same plan.
CAREYLet's say in theory his wife is covered from her job, to Louise and Ceci's point, the children are covered through the children's health insurance program or Medicaid, they often work in tandem. Kevin could go to community health centers in his area that often allow you to pay on a sliding scale, explain the situation. Sometimes there are options at the community level. There may be some kind of state program. I'm not really familiar with all of them in Texas. There may be other options out there for him. But just think about it. You could have, in one house, four -- you know, at least three different ways this family is getting health insurance. That seems kind of crazy.
KEVINIt is, and my initial research shows that our income is too high for the kids to be on CHIP or Medicaid.
CAREYOkay, well that's the thing because sometimes states, Texas is one of them, set the eligibility level fairly low. In that case, it may be you and the kids looking for health at a local community health center. There are -- they're all over the place. You can find some on the Internet, and it would -- you would just explain the situation to them, see their sliding scale, and what can they do for you with anything.
REHMKevin, I wish you luck. That is a terrible story. And I sure hope it doesn't lead to divorce in your household. Let's go now to Melrose, Florida. Harriett, you're on the air.
HARRIETTYes, thank you for taking my call. Unfortunately I know maybe a little bit too much about this subject as I've worked as a nurse practitioner for 15 years and in nursing for over 33. I watched my premiums go from $300 a month under an employer to $450 a month with a $1,500 deductible, and that was prior to the ACA taking effect. And then when it did take effect, and I tried to price what it would cost me as an individual without a subsidy, it was certainly more than 10 percent of my income.
HARRIETTIt would be prohibitively expensive for me, over $1,000 a month, or I could get -- for $750 I could get a plan with a $6,000 deductible, sorry, HMO plan. So my question is, whatever happened to the part of the law where the insurance plans were only allowed to go up by a certain percentage per year? And then another part of my question goes to the health Research Institute guest that you have. I know the Commonwealth Fund did a study in 2011 showing that the average cost per person per capita in the United States for health care was over $8,000, comparing the United States with 11 other countries, and the outcomes in the United States were at the very bottom.
HARRIETTFor instance in England they pay on average about $3,000 and in Switzerland about $4,000 per capita.
REHMRight, right. I wonder if you can talk about what happened on the caps that were supposed to be on the Affordable Care Act, Mary Agnes.
CAREYI am actually -- I'm going to look at Louise on this one. I am not aware of any kind of price caps that were set as far as premium increases. There are out-of-pocket caps. There are limits that the policies can have. For an individual next year that's around $6,700. For a family plan it's around $13,700. I wonder if that are the caps that the caller's referring to. And also one thing to keep in mind, while those are incredibly high, they didn't exist before the Affordable Care Act. You didn't have these caps on out-of-pocket costs.
REHMAnd you're listening to the Diane Rehm Show. Do you want to comment?
RADNOFSKYThe health law doesn't cap premiums to my knowledge, either. It does include new tools to help states review the rates that are suggested to them, and it allows the federal government to demand that insurers publicly justify in other states why it is that they're trying to increase premiums over 10 percent. But crucially, the federal government cannot deny that. They can just sort of engage in a public shaming process.
RADNOFSKYAnd what we've seen this year is that that hasn't been a deterrent, that regulators have approved the big increases and that the federal government has been powerless to stop them.
REHMAnd here's our last email, from Kate in Dallas. And I'll bet lots of folks are thinking this way. She says, we need to get the insurance companies out of the middle of this. When we go for health care to a doctor's office, we should be able to walk in, swipe our universal health care card, walk out. This is how my French sister-in-law, who runs a clinic in Marfa, Texas, gets her health care in France. Our insurance system is unacceptable and insulting and needs to be abolished. How about that, Ceci?
CONNOLLY(laugh) Well, she's certainly not the only person that feels that way, but historically Americans have not been inclined to support what's known as single-payer health care or essentially a government-run program similar to the one that she mentions in France. Health care is indeed very, very expensive in this country, too expensive, as Harriett pointed out. And what are we always getting for our money?
CONNOLLYI would suggest to you, though, that millions of Americans have gotten some health care coverage over the past few years as a result of this law, and we are seeing the rate of increase slowing down a little bit. So far from raving success, but we see little signs of improvement.
REHMWhat do you think, Mary Agnes?
CAREYI don't see, you know, her vision of health care happening any time in the future politically on Capitol Hill, absolutely not.
REHMHow about you, Louise?
RADNOFSKYAbsolutely, I do think that in the coming years the thing to watch, though, is the rate of the remaining uninsured. It's a very important part of the story of what the Affordable Care Act has done and what it hasn't done.
REHMWell, I think even though, as you said Ceci, you don't have a majority wanting a universal health care plan, there sure are a lot of people who'd like to see it. And I must say a lot of people I know. Thanks to all of you. Mary Agnes Carey, Louise Radnofsky and Ceci Connolly, thanks to our callers, our emailers, and thanks to all of you for listening. I'm Diane Rehm.
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