There continues to be marked confusion about the status of the Affordable Care Act (ACA) that was passed in 2010. The Republicans in the U.S. Congress have tried to repeal the ACA more than 40 times, and their efforts have been unsuccessful. Staunch conservatives have ramped up pressure on Republicans in Congress and the Senate to make efforts to repeal the ACA before its major provisions go into effect in 2014. The results of so many ACA repeal sound bites have many Americans thinking the ACA has been repealed, and consequently, some may not have been using or seeking benefits, such as private insurance through state insurance exchanges. Some say conservatives are highly concerned that the ACA will be successful providing health care access and in cutting costs, thereby creating satisfaction with the ACA among voters. This could be a major issue in the 2016 presidential campaign. The Obama Administration has begun to do public service announcements and Webcasts to enhance Americans’ understanding of what the benefits of the ACA are and how they can obtain them. Many are concerned that these efforts are too little and coming too late in the game.
Ambulatory care nurses and other providers in ambulatory care settings need to be conversant on both ACA benefits and how to access and use the state-based insurance exchanges. Private foundations, such as the Kaiser Family Foundation (KFF), have designed their Web sites for ease of use and provide many up-to-date issue briefs, slide sets, videos, and analyses that will be summarized in this column. The KFF document "An Early Look at Premiums and Insurer Participation in Health Insurance Marketplaces, 2014" (Cox, Claxton, Levitt, & Khosla, 2013) provides insurance information and tables that spell out actual costs and cost savings for persons with low incomes.
The ACA provisions provide the opportunity for individuals and families to purchase private insurance coverage through new state-based exchanges, also called "Marketplaces," which opened in October 2013 and offer coverage beginning January 1, 2014. Some states have opted not to set up their own exchanges, and in these states, the federal government will either run the exchange or work in partnership with the state to create an exchange. "Regardless of whether an exchange is state-run or federally facilitated, enrollees with family incomes from one to four times the federal poverty level (about $24,000 to $94,000 for a family of four) may qualify for tax credits that will lower the cost of coverage through reduced premiums, and in some cases, also be eligible for subsidies to reduce their out-of-pocket costs" (Cox et al., 2013, p. 1). The KFF report looks at insurer participation and exchange premiums – both before and after tax credits – for enrollees in 17 states plus the District of Columbia that have released data on rates or the rate filings submitted by insurers (Cox et al., 2013). Of those presented, 11 states operate their own exchanges, and seven have a federally facilitated exchange.
In January 2014, the ACA will provide three major benefits: private insurance at affordable prices, a ban on annual limits for coverage, and coverage for those with pre-existing conditions. Plans offered in the state exchanges, as well as insurance coverage sold to individual and small businesses outside the exchanges, must meet several new regulatory requirements (Fernandez/Congressional Research Service, 2011). The ACA provisions state that insurers must cover a minimum set of services called "essential health benefits." At a minimum, essential health benefits "must include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health, and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness and chronic disease management, and pediatric services (including oral and vision care)" (Fernandez/Congressional Research Service, 2011, p. 2). Further, insurance carriers must organize plan offerings into five levels of patient cost sharing (catastrophic, bronze, silver, gold, and platinum, ranging from least to most protective). Insurers will only be able to vary premiums by age (to a limited extent), tobacco status, geographic region, and family size (Cox et al., 2013).
The KFF (Cox et al., 2013) explains considerations that impact cost of an insurance premium and offers examples of typical premiums. Bronze plans cover 60% of health care costs when averaged across all enrollees, have the most cost sharing, and therefore, represent the lowest level of coverage available through exchanges. Consequently, bronze plans typically have the lowest premiums; they vary significantly across geographical areas and by age but are also significantly reduced by subsidies for low-income populations. Catastrophic plans will be sold on the state exchanges, but will only be available to people who are under 30 years of age or would have to spend more than 8% of their household income on a bronze plan (Cox et al., 2013).
What impact will state insurance exchanges have on premiums for individuals and families who do not quality for subsidies? A recent New York Times article highlights, "State insurance regulators say they have approved rates for 2014 that are at least 50% lower on average than those currently available in New York. Beginning in October, individuals in New York City who now pay $1,000 a month or more for coverage will be able to shop for health insurance for as little as $308 monthly. With federal subsidies, the cost will be even lower" (Rabin & Abelson, 2013).
There are several other resources available on Web sites. The U.S. Department of Health and Human Services (DHHS) (2013) offers on its Web site the opportunity to click on a state to learn about current insurance statistics and benefits available. KFF (n.d.) offers a subsidy calculator that can assist patients with determining what level of subsidy they may qualify for when purchasing health insurance at a state insurance exchange. The National Association of Insurance Commissioners (2010) offers on its Web site an excellent set of frequently asked questions (FAQs) by consumers and employers with very concise answers. This FAQ site can be used as a resource to inform providers and be shared with patients and families. Ambulatory care nurses are only too aware of the need for reasonably priced health insurance for patients and families. The United States finally has an Act, the ACA, that offers the opportunity for access to health insurance and health care, but we must do much more to spread the word and assist patients and families with this new opportunity.
Cox, C., Claxton, G., Levitt, L., & Khosla, A. (2013). An early look at premiums and insurer participation in health insurance marketplaces. Retrieved from http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-...
Fernandez/Congressional Research Service. (2011, January 3). Grandfathered health plans under the Patient Protection and Affordable Care Act (PPACA). Retrieved from http://assets.opencrs.com/rpts/R41166_20110103.pdf
Kaiser Family Foundation (KFF). (n.d.). Subsidy calculator: Premium assistance for coverage in exchanges. Retrieved from http://kff.org/interactive/subsidy-calculator
National Association of Insurance Commissioners. (2010). Health care reform frequently asked questions (FAQ). Retrieved from http://www.naic.org/index_health_reform_faq.htm
Rabin, R.C., & Abelson, R. (2013, July 16). Health plan cost for New Yorkers set to fall 50%. New York Times. Retrieved from http://www.nytimes.com/2013/07/17/health/health-plancost-for-new-yorkers...
U.S. Department of Health and Human Services (DHHS). (2013). How the health care law is making a difference for the people of Illinois. Retrieved from http://www.hhs.gov/healthcare/facts/bystate/il.html
Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at firstname.lastname@example.org