Healthcare

South Floridians’ biggest question about Affordable Care Act health plans: Will they be affordable?

 

pborns@MiamiHerald.com

One 47-year-old cancer survivor thinks the Affordable Care Act could save her life. But a 28-year-old real estate agent sees the law requiring health insurance for everyone as a safeguard he doesn’t need. And for an immigrant nursery worker in southern Miami-Dade County, health insurance is a luxury she never thought she could afford — and is afraid she still can’t.

South Floridians are sifting through information about the most sweeping social program to affect Americans since Congress enacted Medicare in 1965. How will the law, with all its complexities, affect them? For many, the most important question to be answered is: How much will it cost?

One group the Obama administration hopes will sign up for health insurance in the new marketplace opening next month are young adults between 19 and 34, the so-called “young invincibles,” whose attitude about health insurance was presumed to be: “It won’t happen to me.”

But a Kaiser Family Foundation poll finds that more than three-quarters of young adults regard health insurance as important. Carmella Guiol is one.

“I’m worried because in a few months I’ll no longer be on my parents’ health plan. I’m using the time I have left to go to the doctor as much as possible,” says Guiol, 25, who makes preserves and raises chickens at her Coconut Grove home. The Affordable Care Act enabled Guiol to remain on her parents’ insurance plan after college — but that benefit ends when an adult child turns 26. Now, under the latest provision of the law, she’ll be able to sign up for individual insurance on the marketplace.

“My only alternative would be not to have health insurance,” she said.

She hopes the health plans on the new exchange will be compatible with her preference for alternative treatments, a preference shared by four in 10 Americans, according to the National Institutes of Health. The ACA encourages those benefits with a clause requiring insurance companies to reimburse any health provider with a state-recognized license. Cigna, for one, will cover the treatments when they’re medically necessary and offer a discount program for people who want to use them to maintain their health, a company spokesman said.

Accidents or sudden illnesses concern two-thirds of the young invincible age group, according to Kaiser. But Guiol — who has worked as a farmer, a baker and a nanny, all without an employer health plan — doesn’t have hundreds of dollars a month to spend on coverage.

Her income may qualify her for a federal subsidy. Subsidies will be offered on a sliding scale for those between 100 percent and 400 percent of the federal poverty level. The poverty level is $11,490 for an individual and $23, 550 for a family of four.

Guiol is also considering enrolling in a catastrophic plan, available for people 30 and younger. Under the healthcare law, such a plan would cover essential health benefits, but only after out-of-pocket cost sharing reaches a high deductible. Her backup plan? Having a French father, she was able to obtain a European Union passport to have access to European healthcare.

But other “young invincibles” aren’t so interested in spending money for insurance. At 28, Edward Escobar has been uninsured for two years, but not for lack of funds. “The idea of just giving away my earnings to an organization that doesn’t have my best interest at heart isn’t a good definition of using my hard-earned money wisely,” said Escobar, a Miami real estate agent.

He sees putting his money into advertising to sell more real estate as a better investment. Personal experience with the high cost of medicine has made Escobar reluctant to pay into the system. When his grandmother was in the hospital, he saw bills charging her almost $100 for a Tylenol pill. “Because it lies in a hospital, it costs more? To me, that’s price-gouging.”

While he supported the ACA, even writing to urge his congressional representatives to vote for the law, Escobar sees it as the first step in a process. “All we’ve done so far is give insurance companies and hospitals a new pool of people who need their services,” he says, while the cost of the services continues to escalate. He doesn’t think he’ll need those services anytime soon. If he has an emergency: “I’ll pay the hospital back on whatever terms we can negotiate.”

A high-deductible catastrophic health plan might make Escobar take a second look at the health exchange, but only if the cost is low enough — he’s willing to pay no more than $25 a month, he says. He might also reconsider when confronted with the penalty for those who opt out of insurance. Under the law, the penalty in 2014 will be $95 for an adult or $47.50 per child, for a total of up to $285 for a family or 1 percent of income, whichever is greater.

“I’ll have to talk to my accountant,” Escobar said.

Protecting assets from high healthcare costs is something people in Steve Hagan’s over-50 age group can relate to. A Miami public parks activist who has been self-employed as an importer since he was Escobar’s age, Hagan bought individual insurance until he turned 50, when his premium skyrocketed. He was told that in 10 years the rate would be more than $1,000 a month.

So Hagan switched to a bare-bones plan, a strategy many employ to build their savings for retirement. Even then, the premium crept up to $600 a month. Regular checkups would have told him his cholesterol was creeping up, too, but his plan was for hospitalization only, and there was no room in his budget for routine care, he says.

One Friday night, Hagan felt pains in his neck and arm. The heart attack was mild. His three stents cost the insurance company $9,200. Had he been uninsured, he would have been charged $109,000, according to what he says the hospital told him. In 2010, Hagan got his first wellness exam in 12 years, a benefit of the ACA, which required all health plans to cover preventive care such as physical exams. In 2014, he’ll have prescription coverage, one of the “10 essential benefits” that all health plans must provide under the law. He currently buys his prescriptions on the Canadian market for what he says is a fraction of the U.S. price.

The ACA will also limit what an insurer can require him to pay in out-of-pocket costs — deductibles and co-payments — to a maximum of $6,350 for an individual. For a family, the amount is $12,700. People in group plans will have to wait for that benefit until 2015.

Hagan’s premiums will be higher than Guiol’s and Escobar’s because of his age, unless he qualifies for a subsidy, but he could still see substantial savings under the ACA, because people over 50 can’t be charged more than three times the rate of young people for the same health plan.

Will he bite? He’s not sure. Now 64, Hagan will qualify for Medicare in a few months. “My insurance on Medicare will drop to $150 a month. It will be like getting a $600 raise,” he says.

Health premiums may have cost him more than he wanted to pay, but some people are unable to get coverage at any price.

“Thank you for your application for health insurance coverage,” began the letter addressed to Deborah, a 47-year-old healthcare professional who asked not to use her full name because she’s looking for a job and worries that her medical condition will be held against her. “Unfortunately, we are unable to provide health coverage to you for the following reason ...”

When Deborah was first diagnosed with Stage 2 breast cancer, the nursing professional from Plantation was covered by health insurance from her employer. When the cancer returned, she had gone back to school to become a nurse practitioner, so she was covered under the school’s health plan. But since graduation in 2012, Deborah has been refused health coverage by every health insurer she’s applied to. She says she drained her 401K to pay for her care.

Families USA, a national nonprofit focused on affordable healthcare, estimates that more than 7.8 million Floridians have a preexisting condition such as diabetes, high blood pressure, asthma or, like Deborah, a history of cancer. Starting Jan. 1, under the ACA, companies must accept everyone. No one can be denied or charged more because of their condition. Nor can coverage be cut off if you get sick.

The Obama administration hopes to draw another group into the health exchange: people climbing out of poverty into the lower middle class who have never been able to afford coverage. The lunchroom at Plants In Design, a bromeliad nursery in Homestead, fills with conversation as workers from a half-dozen Latin American countries file in from the greenhouses. The 49 employees — all with full-time jobs, vacation pay, overtime and bonuses, but no health insurance — are among those likely to qualify for the highest health premium subsidies under the health reform act.

Today, Rosa Corea’s three children are covered by Medicaid. Healthcare for her and her husband, who packs vegetables, consists of exams at a sliding scale clinic, and getting charged full price for everything else.

When her husband was in a car accident and went to Homestead Hospital, “They ran tests, sent him home, and charged him $36,000,” Corea says. His car insurance covered half the bill. Two years later, he’s still paying off the balance in $50-a-month installments arranged with the hospital.

Corea heard about the ACA on the news and knows she’s required to get health coverage. She’d like to be able to see a doctor and have hospital care if needed, but worries she can’t afford it.

“Without insurance, we could keep doing what we do now. You always look for the most economical thing to do.”

Corea’s employer, Ashley Trop, is on the same page when it comes to doing what’s most economical. “If I had 50 employees, I’d be freaking,” says the former firefighter and attorney, referring to the ACA mandate that employers with more than 50 employees must insure them or pay a fine.

While the plant nursery is profitable enough to provide the coverage, he thinks all his employees will qualify for subsidies. In Corea’s case, a subsidized health plan could cost less than $40 a month, according to estimates provided by the Kaiser Family Foundation subsidy calculator recommended by the official ACA website, healthcare.gov.

But Trop doesn’t want his workers to pay out of their pockets. He thinks a $1,000 annual raise, which he’s willing to give each of them, would be enough to make up for their premiums.

“Call me a burned-out hippie, but I believe in a living wage,” he says.

This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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