When Congress began debating the Affordable Care Act back in 2009, Charlotte Ash had high hopes it would improve America's health care system.
As director of the Snake River Community Clinic in Lewiston, she's seen firsthand the effect a lack of insurance and regular medical care has on the lives of her patients.
The clinic, which relies entirely on donations and volunteers, provides free health care for the working poor - people who typically earn less than $20,000 per year and who, at times, literally have to choose between buying food and buying medication.
"We were really excited when (the Affordable Care Act) first came out," Ash says. "We thought people would be covered. But after reading the bill, it's not going to be what everyone expects it to be. It's not going to change things for a lot of people because it isn't realistically affordable."
That will become more apparent before long.
NEW YEAR, NEW MANDATE
Beginning Jan. 1, the Affordable Care Act, also known as Obamacare, requires all Americans to have health insurance coverage or pay a penalty, unless they qualify for an exemption.
The intent is to eliminate the "free-rider" problem, in which the cost of treating uninsured people gets shifted to those who have insurance, adding hundreds or thousands of dollars to their annual premiums.
The Urban Institute, a nonpartisan economic and social policy research center, estimates about 18 million uninsured people will be required to purchase health plans under the mandate, or 6 percent of the total population. Most Americans will satisfy the requirement through coverage at work or through a government health plan like Medicare or Medicaid, or they'll qualify for an exemption.
However, the mandate doesn't just apply to adults: Children must be covered as well. If they don't qualify for Medicaid or the Children's Health Insurance Program, parents will either have to add them to their plans at work or buy a separate policy.
And these new policies can't be limited to catastrophic coverage. They're required to provide a comprehensive set of "minimum essential health benefits," which Congress has defined to include everything from maternity and newborn care to substance abuse treatment and chronic disease management.
THESE REQUIREMENTS MEAN INSURANCE WON'T BE CHEAP
The Congressional Budget Office estimates annual premiums will average about $5,200 for an individual health plan by 2016, and $14,100 for a family policy.
Those who qualify for tax credits may still struggle to pay.
About 11 million of the 18 million uninsured will qualify for federal tax credits and subsidies, according to the Urban Institute. That could save them thousands of dollars each year, but many will still have difficulty paying for the plans.
For those who earn 100 percent to 400 percent of the federal poverty level - roughly $11,490 to $45,960 for individuals and $23,550 to $94,200 for a family of four - their share of the premiums will range from 2 percent to 9.5 percent of household income.
That's about $20 per month at the low end of the scale, but quickly swells to car-payment or house-payment range the higher one goes. At the top of the scale, a family of four is looking at almost $750 per month.
IRS RULING LIMITS SUBSIDIES FOR FAMILIES
It could be even higher for some, based on a recent Internal Revenue Service ruling. The agency decided in January that if someone is eligible for an employer-sponsored health plan and the monthly premiums don't exceed 9.5 percent of family income (for single coverage), then their spouse and kids won't qualify for federal subsidies. They'll have to add them to the employer plan and pay much higher premiums, or buy a separate policy at full cost - or leave them uninsured and pay the tax penalty.
How many people will go the penalty route "is the million-dollar question," says Shad Priest, government affairs director for Regence BlueShield of Idaho.
The penalty for not having insurance starts out at $95 per adult in 2014, or 1 percent of taxable income, whichever is greater. It increases to $695 per person or 2.5 percent of income in 2016.
Beginning next year, the Affordable Care Act also prohibits insurers from denying coverage for pre-existing conditions. This leads some critics to suggest it merely creates a modified version of the free-rider problem, in which people will choose to pay the penalty and remain uninsured until they fall sick - after which they'll buy insurance, add to the cost of care and contribute to higher premiums for everyone.
TO SAVE MONEY, SOME MAY PAY THE PENALTY - UNTIL THEY GET SICK
"There are about 280,000 uninsured in Idaho," Priest says. "You have to look at their income levels, the type of subsidies they'd be eligible for, their health status. When you take all those factors into consideration, everyone comes up with a different number (for how many will choose to pay the penalty). But it's a big concern. If healthy people stay away, it just creates a sicker insurance pool."
The Congressional Budget Office estimates only 2 percent or 3 percent of the uninsured will take this route, but with just a $95 penalty initially, the number could be much higher at first.
Priest also notes that health plans will have limited enrollment periods, so this option comes with the risk that someone won't be able to get insurance as quickly as they need.
Nevertheless, Ash says she expects most clients at the Snake River clinic to pay the penalty, at least the first year. Although the federal subsidies would dramatically reduce their premiums and cut their out-of-pocket expenses, even $20 or $30 a month is too steep for someone who earns less than $12,000 per year - and that's just for the premiums; it doesn't include deductibles or co-pays.
"They aren't going to be able to afford it," Ash says. "There will still be a big gap where people won't have health care."
BUSINESSES MAY TURN TO TEMP WORKERS
Some businesses may pay penalties or move toward part-time employees.
Tedi Roach, the owner of Express Employment Professionals in Lewiston and Moscow, says temporary workers could also be a solution for some firms.
"All of our associates have insurance through us," she says, so a company that needs to add workers could hire temps and avoid crossing the 50-employee threshold.
State Rep. John Rusche, D-Lewiston, was recently appointed to the board that's setting up Idaho's insurance exchange or online marketplace. He says educating consumers about the choices available to them will be an important function of the body.
"We've set up a marketing and outreach committee," he says. "I think we'll find the technical issues are going to be less difficult than getting people to understand what's available and helping them do good comparison shopping."
He noted the soaring cost of health care and barriers to access were the main issues that drove Congress to adopt the Affordable Care Act. To the extent the individual mandate doesn't resolve those problems, Rusche says, "I think it will change. But it's going to take time to see how it plays out."
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