Inside Obama Care
It’s a recent Sunday afternoon at St. Peter the Apostle Roman Catholic Church in Libertytown and Max Ebert is on a bit of a hot seat.
As one of 15 “navigators” and other assistants helping Frederick County residents create Affordable Care Act (ACA) accounts, he stands in the midst of an issue that has been publicized, politicized and polarized– and well-fueled on this day by the recent failures of the federal Obamacare web site. “Is this the healthcare.gov that we hear about on the news?” asks Deacon Jerry Jennings, who helped organize the recent info session. Ebert responds that the web site Marylanders use to enroll in the ACA (marylandhealthconnection.gov) is different than the federal, headline-grabbing site. “No, our site is running much smoother than that,” Ebert says, though he admits one month after the Oct. 1 launch, there are still bugs being worked out.
“It’s getting faster, I can tell you that as someone who is on it all the time.”
The Great Recession of 2008 tipped all kinds of sacred cows—and regular doctors’ visits for many Americans were among them. Middle-class folks who never had to worry about a stable income, a family vacation or a lifestyle that included new cars and well-furnished homes were instead coping with lost jobs, cancelled vacations and hourly work in restaurants, discount stores and warehouses.
But if that wasn’t bad enough, when there are middle-income breadwinners in jobs without health benefits, people quickly miss the physicals, sore-throat checkups and pre-emptive doctor visits to their family doctor or dentist. The federal Affordable Care Act, also known as Obamacare, was supposed to address that.
Here in Frederick County, people are already experiencing the earliest effects of the law: their 20-something children can now stay on their health insurance plans and co-pays have been eliminated for preventative well-child and gynecological visits. “People don’t realize how many parts of the Affordable Care Act have already benefited them before insurance enrollment even began,” says Jackie Douge, deputy director of the Frederick County Health Department.
But those steps were merely a vanguard to the biggest move of all: the estimated 23,000 people in Frederick County (and 250,000 in Maryland) who had no insurance are now eligible for government-sponsored health care via expanded Medicaid coverage or a plan under Maryland’s new Health Care Exchange.
A New Kind of Uninsured
Frederick County’s public health providers began to meet a year ago to lay out a system for rolling out the ACA, and determined 10 percent of Frederick County’s population had no insurance. This number had increased from 4.2 percent in 2002 and continues to rise, say public health officials. And organizations in Frederick County who provide indigent care have found their rolls growing larger and larger.
“We’ve been seeing lots of people in their 50s and 60s who are now without jobs; people who work at places like Golden Corral,” says David Richards, a longtime volunteer at Mission of Mercy, a free clinic for Central Maryland and Pennsylvania residents. Between checking in patients, he and nurse volunteer Dean Baldwin say a new type of visitor is beginning to arrive at the clinic doors: employed workers. “We are starting to get people who have been dropped from insurance by their company totally, or their spouse,” Baldwin says.
“Underinsured” or substandard insurance—lacking coverage for many treatments, with unreachable co-pays and deductibles or uncovered family members—is on the minds of doctors and nurses when it comes to health care in Frederick County. “The issue is the shift in demographics, and the fact that people have substandard medical insurance,” says Dr. Julio Menocal, a Cuban family practitioner who left the comfort of Parkview Medical Group in 2006 to dedicate his practice to the growing low-income demographic—especially Latino—in the Golden Mile area.
“I am seeing more and more white-collar people with college degrees who do not have coverage for many things they need.”
Medical assistance patients make up more than 70 percent of his patients, he says, and the ACA “is going to save my practice.” He says that’s because in January, primary care physicians’ reimbursements for Medicaid will rise to attract more physicians to increase their numbers of Medicaid patients, which could boost reimbursements for many diagnostic procedures an average of 64 percent, according to an analysis by the Urban Institute. “With no rate increase since I began, I was in a position to reduce the number of Medicaid patients I see,” he says. The measure should help the coming shortage of primary care doctors, he hopes. However, “not all clientele of family doctors are going to be willing to sit next to someone poor in the waiting room.”
So how do people find a way out of being uninsured or underinsured, with fingers crossed each day that they would stay healthy?
Ebert is employed with Healthy Howard, the nonprofit entity contracted to oversee the on-the-ground signups and promotion of the ACA in Frederick County. Healthy Howard oversees enrollment at the organization where he is based, the Frederick Community Action Agency, as well as the Asian American Center of Frederick, the Frederick County Health Department and Frederick County Department of Social Services.
Officially, Healthy Howard advises that if a person logs onto the Maryland site and has all the needed information required to create an account, he or she should be able to receive a password, shop for a plan and make a selection within 45 minutes. “Have your social security number, a pay stub, W-2 or last year’s tax return, and your employer’s tax identification number,” Ebert says. This information enables online verification and is the key to determining whether a person’s income qualifies them for expanded Medicaid coverage or whether a subsidized plan is available.
“People just don’t realize they qualify for this, and it’s my job as the parish nurse to connect them to resources,” says MaryBeth Terrell of St. Peter the Apostle, who says getting the word out about the ACA is even more challenging in a Catholic parish, where the law is unpopular. “But health care is a basic thing to everyone, and I hear all the time from people who need it.”
Public health officials agree. It’s not hard to connect low-income people who are already using other health and social services to the Maryland Health Connection navigators; the more challenging audience to reach is middle-class workers. “People just don’t realize they are eligible, and they need to check and find out,” says Douge.
For the St. Peter the Apostle audience, Ebert’s slides offer an optimistic view for those who have been unable to fit health care in their monthly budgets.
The Maryland Health Connection offers plans from private insurers that range from a stripped down Kia to a loaded Cadillac. They fall into four classes, beginning with bronze as the slimmest coverage and moving up through silver and gold before reaching platinum as the most comprehensive plan. Not all the insurers offer all levels; in Maryland, there are 11 bronze plans, 16 silver, 12 gold and three platinum. The bronze has the lowest premium but only covers 60 percent of typical health care expenses; silver, a bit higher premium with 70 percent of expenses covered; gold, 80 percent of expenses are covered; and and platinum has the highest premium but covers 90 percent of typical health expenses.
“You have to pick a plan you’re comfortable with, depending on what you can pay and how healthy you are,” Ebert advises.
Another reason for the “A” in affordable, Maryland health care officials say, is the subsidies applied to premium payments, which can be used to either reduce monthly payments or be taken as a lump sum at tax time. Some of the Maryland Health Connection estimates have been surprising to the middle-income attendees of navigator information sessions, officials say, showing that a family of four with income of $94,200 is eligible for a tax credit. “They cast a very wide net so they can help as many people as possible to get affordable insurance,” Ebert says.
There is a catch, though. Health conditions and disabilities will affect which plan is cost-effective. For example, someone with a chronic heart condition who chooses a bronze plan because of its low premium would face a high deductible and limits on coverage they may otherwise wish they had, such as hospitalization and complicated diagnostic testing. Jennifer Teeter, a Frederick Memorial Hospital official overseeing ACA enrollment, notes that the presumably budget-friendly decision can land people in the emergency room because they cannot afford expensive procedures with beyond-their-reach deductibles. “That high deductible seems like a great thing because the premium is low, but if something serious happens to you, it doesn’t do you much good,” she says.
Sorting through the choices and likelihood of needing them based on your health needs is a challenge that public health workers say is making the enrollment process more difficult and lengthier than billed. Even though federal officials have used booking a flight on Expedia or purchasing from Amazon as examples, “we say it’s a 45-minute process, but you should really take your time to look through all the options for the right plan,” Ebert says.
Take the story of LaShell Bell, a nursing student from Brunswick whose income from part-time work brought in too much money for her to qualify for Medicaid. She had just filled out an application for individual private health insurance with a private individual insurer when she began having severe headaches and started a round of visits to her doctor and specialists seeking a solution. The only coverage she could afford required a $5,000 deductible in return for her $86 monthly payment. After thousands of dollars in visits, MRIs and a hospital stay that confirmed multiple sclerosis, she is now paying out of pocket because her insurer denied her claims, citing her first doctor’s appointment for a headache as a pre-existing condition.
Bell is now working to enroll in the ACA but has been frustrated, first by an inability to log onto the site during the evening and weekend hours when she is not at school or work; then by an inability to get her account established even after a phone call with an assister from the Maryland Health Connection. So far, she has only been able to browse through the site for plans which “are $150 a month at the lowest. That’s not something I can afford.”
She says she has many friends who are in similar circumstances. “I feel like I must be the working poor; I can just never get ahead,” she says. “I know a lot of people like me, who make too much for Food Stamps and help, but we can’t afford to take these plans; so I have faith that once they iron out the ACA, it will be OK.”
What Happens Next?
Douge says as a public health official, she hears the frustration but says people need to give the ACA time. It provides a level of care, even at its most minimal plans, for people who had no option for care but the emergency room previously. “Large-scale programs with social change take time,” she says.
Teeter, the FMH official, agrees. The hospital has seen its charity care budget (the cost of providing service to uninsured patients) balloon by more than $1 million a year—from $5.8 million in 2009 to $9 million in 2012—and officials are especially troubled by how much of the cost is due to avoidable visits. “We see the results of people not having coverage every day here in our ER,” she says. “So often they are hospitalized for a chronic condition that is entirely avoidable.”
The hospital plans to assign navigator duties to a staff member soon, to work to move uninsured patients into the Maryland Health Connection—and is working to focus on other provisions of the ACA that encourage preventive care and education aimed at keeping people out of—or from returning to—the hospital. “This transition is an uncomfortable time for many people in the community,” she says. “But care management and prevention programs—it goes to the heart of our mission.”