At the Kansas City CARE Clinic on Broadway, the waiting room is half full: the young, the old, the in-between, all seeking time with a doctor or nurse.
By DAVE HELLING
The Kansas City Star
In the corner, a large sign.
“The health insurance marketplace is coming!” it says. “¡El mercado de seguro de salud está viniendo!”
A promise? A threat? A bilingual ad?
Try all of the above.
Starting Oct. 1, more than 1 million uninsured Kansans and Missourians will, for the first time, have full access to a computer-based health insurance marketplace at www.healthcare.gov. There they can see and compare qualified health plans and prices and perhaps obtain tax credits to pay for the coverage the law says almost all Americans must have by the end of the year.
It’s a critical part of the Affordable Care Act. It sounds simple enough.
But local experts are nervous. The enrollment process, they say, will present the uninsured with a complicated blizzard of choices that can befuddle even those who have had insurance for years:
• Enrollees will have to understand what deductibles and co-pays are and how to compare policy premiums with coverage options. Choices will include plans ranging from bronze — the cheapest, providing coverage for about 60 percent of health care costs — to platinum, the most expensive and broadest plan, covering roughly 90 percent of eligible expenses. Gold and silver plans will also be available.
In general, younger and healthier uninsured clients are expected to pick the cheapest option, while sicker purchasers may gravitate toward expensive coverage — assuming they can pay the higher premiums.
• People will need to estimate future earnings and understand the tax implications of their choices. Tax credits, based on projected income, will be available to pay part of the cost of premiums for some buyers.
They will need to know if their employer offers “affordable” insurance. If so, premium subsidies and credits might not be available.
Premiums and access may vary by age and family status too.
• Would-be enrollees already on Medicaid or Medicare won’t need to use the marketplace, nor will almost anyone who gets insurance at work. Some small businesses will use the marketplace for their workers.
• Insurance options may vary by state. Enrollees will need to understand whether their doctors accept health insurance and how to file claims.
• Enrollment may be technically challenging, for enrollees and the government.
Early tests have exposed possible database glitches. Enrollees may not have access to a computer, may not understand how to use one or may not want to. Phone banks will be in place, and some insurers might offer walk-in counseling and service.
Play or pay
Doing nothing isn’t a legal option for almost all uninsured Americans. But because the tax penalty for failing to buy insurance is relatively low, especially in the first year, many may avoid the marketplace and take their chances with the IRS.
And some may do nothing because they don’t know about the marketplace. Surveys suggest a large number of Americans are unaware the ACA is the law.
In late June, Gallup said 43 percent of uninsured Americans the pollster talked with didn’t know the law requires coverage.
It’s a difficult, complicated challenge for enrollees and providers alike.
“Are there going to be hiccups? Absolutely,” said Dennis Dunmyer, vice president of community services for the CARE Clinic, where low-income Kansas Citians have gone for free and reduced-price health care for decades.
“Will we be able to navigate it successfully? Yes.”
In fact, Dunmyer and dozens of other health care stakeholders are working diligently — and spending millions of dollars — to reach the uninsured and explain how the options will work.
They are touting the benefits of insurance. It will cover expenses from an accident or chronic disease, lessening the burden of sickness or injury, they say. You can’t be turned down for a pre-existing illness. Out-of-pocket costs can be capped.
Obamacare under fire
But enrollment efforts have been complicated because of ongoing opposition to the ACA, often called Obamacare, from many conservative legislators and policymakers.
Missouri and Kansas have turned down outside money and expertise, which means residents will rely in full or in part on the marketplace established by the federal government. The states’ conservative leaders have declined chances to explain the system, instead criticizing Obamacare at virtually every opportunity.
Some conservative interest groups have urged the young to boycott the marketplaces.
In Missouri, state officials say they are forbidden from helping residents enroll, even in the federal marketplace.
“I’m not interested in giving the federal government any more power,” House Speaker Tim Jones, a Republican, said in November.
Last Tuesday, Gov. Jay Nixon anticipated public frustration when the federal marketplace opens in October.
“There will be challenges,” said Nixon, a Democrat. “My position was we should have that exchange at the state level, but the legislature and others decided not to.”
After lawmakers and voters reached that decision, local health care insurers and providers — eager to make the marketplaces work — began fashioning their own responses.
Providers have published brochures and newsletters explaining concepts and options. They have trained staff to answer questions and refer the unenrolled to the federal marketplace. Some health clinics in Kansas and Missouri are using federal grants to reach out to clients and their families.
The Missouri Foundation for Health, a philanthropic group, has announced plans to spend more than $8 million to reach the uninsured. A website it help set up at www.covermissouri.org is designed to replicate many of the questions clients will face in the federal exchange.
Washington recently awarded $2.7 million in grants to Kansas and Missouri “navigators,” people who will be trained to walk health insurance purchasers through the process, helping them understand eligibility and options once enrollment begins. Navigators also can help with appeals if an applicant is denied coverage.
“We’ll do this in a completely unbiased manner. We won’t sell insurance,” said Jeremy Milarsky of Primaris Healthcare Business Solutions, one of two Missouri-based navigators. “It’s going to be a no-wrong-door type of service.”
But health care experts say the grants probably can’t pay for one-on-one counseling between a navigator and every one of the estimated 325,000 people in Kansas and 800,000 in Missouri who lack health insurance but are eligible for the marketplace.
And the navigators are spread out. There is no Kansas City-based primary navigator, for example — the Mid-America Regional Council applied for a grant but was turned down.
“There are going to be significant gaps in Kansas City,” said Scott Lakin, director of MARC’s regional health care initiative and a former Missouri insurance director.
Some navigators, he said, might engage local subcontractors to reach the public more effectively. Primaris, for example, will work with the Shepherd Center of Kansas City to provide navigation services.
Navigators might be caught in a political crossfire as well. House Republicans have asked them to provide information about their grants, which Democrats say is part of an effort to clog the system and make the navigators less effective.
Insurers and providers also are expected to pick up some of the slack.
Blue Cross and Blue Shield of Kansas City, for example, offers a website at www.kchealthcarereform.org for early comparison shopping and is conducting its own outreach effort. Other organizations are ramping up help on their websites.
Clinics, pharmacies, even doctors’ offices also might help guide the uninsured.
Getting the word out
So far, though, Missouri and Kansas have lacked the broad public information campaigns common in other states where state-based marketplaces are in place. Brochures are hard to find. Websites can be hard to use. Mass media promotions are virtually nonexistent, at least so far.
That may soon change. Politico has reported that the Obama administration plans to spend $12 million on ACA television advertising in a dozen states, including Missouri, at the end of September.
Minnesota is spending an estimated $9 million on its media campaign to promote its state-based marketplace, known as MNsure.
MNsure is airing TV and radio commercials, buying print ad space and installing billboards touting its health insurance marketplace.
But Bridget McCandless, director of the Greater Kansas City Health Foundation, said a mass media approach might not be effective. Instead, she said, the foundation will spend $700,000 on a targeted outreach program, then evaluate the results before spending more money next year.
Missouri and Kansas have had some federal help in preparing for the marketplace system, although funding dwindled once it became clear the states would rely on the federal exchange.
Missouri has received $21.9 million for technology and planning, HHS says, while Kansas has received $1 million.
“We’re going to start doing outreach in the next two weeks,” said Sandy Praeger, the Kansas insurance commissioner and a Republican. “Just to try to make sure people understand that they should at least check to see what the benefit might be.”
U.S. Rep. Kevin Yoder, a Kansas Republican, has voted repeatedly to repeal Obamacare. But he thinks his office might become a clearinghouse for potential enrollees who hit a snag.
“We’re absolutely going to help them,” Yoder said, if there are problems.
Missouri, Kansas and Medicaid
Congressional offices might face immediate questions about a complicated quirk in the law involving Medicaid, the state-federal program designed to insure the poor.
Expanding Medicaid eligibility is also a key part of Obamacare, but lawmakers in Kansas and Missouri rejected that expansion.
So hundreds of thousands of residents might find themselves in an earnings “doughnut hole” — too rich for traditional Medicaid, too poor to qualify for the marketplace subsidies.
Erika Neal of St. Louis is fighting ovarian cancer. As an adult with no children, she can’t qualify for Missouri’s Medicaid program, but she doesn’t earn enough to qualify for coverage in the federal marketplace.
And buying coverage on her own would be prohibitively expensive.
While she has fought the tumor for months, she needs tests to gauge her progress.
“Most ovarian cancers, by the time you find out you have it, you just need to plan your funeral. So it’s a blessing they have a test for it, but I can’t get the tests if I don’t have health insurance,” Neal said.
Officials in Kansas and Missouri expect to hear thousands of stories like that once the marketplace opens. Democrats hope the examples will prod Republicans into reconsidering Medicaid expansion next year.
Washington has said it will not penalize taxpayers caught in the health insurance doughnut hole, at least for now. Almost everyone else faces a penalty next year if they fail to buy available coverage.
Health officials in Kansas and Missouri have taken pains to emphasize that the marketplaces will open for business Oct. 1 but won’t close the same day.
The first enrollment period will extend through March, although insurance must be purchased before Jan. 1 to avoid the tax penalty.
So most local officials hope many uninsured will wait a few days before pursuing enrollment.
A little patience, they say, will help clients avoid frustration.
“Don’t go on Oct. 1,” Praeger said. “The benefits don’t start until January anyway. Give it a few weeks.”
Coverage in the marketplace
326,885 are uninsured and eligible
253,194 of that total have a full-time worker in the family
799,255 are uninsured and eligible
585,747 of that total have a full-time worker in the family
Do I have to buy coverage in the marketplace?
No, if you have insurance through:
• Your employer
• Medicaid or the Children’s Health Insurance Program
• Tricare or veterans health program
• Private insurance you bought that’s at least the bronze-coverage level in the ACA
• A grandfathered plan from before the ACA was enacted
No, if you are:
• Part of a religious group opposed to accepting health insurance benefits
• An undocumented immigrant
• In prison
• Part of an Indian tribe
• Too poor to file a tax return ($10,000 single, $20,000 family)
• Paying more than 8 percent of income for health insurance, minus employer contribution or tax credits
Penalties for the uninsured
Where to go for information
Toll-free help line: 800-318-2596; available 24/7
Hotline for hearing-impaired callers with TTY/TTD technology: 855-889-4325
Essential health benefits
All insurance plans, in and out of the marketplaces, must cover these 10 benefits:
• Ambulatory patient services
• Emergency services
• Maternity and newborn care
• Mental health services
• Prescription drugs
• Rehabilitation services
• Laboratory services
• Preventive and wellness care
• Pediatric services
Coverage levels, on average
Bronze plans: 60% of costs