Americans have started shopping for coverage on the new health insurance marketplaces, or exchanges, ahead of more big changes from the Affordable Care Act, the US health care makeover commonly known as Obamacare.
Experts familiar with the far-reaching law say health care reform means different things for different people, depending on where they live, their income, whether their employer currently offers coverage, and numerous other factors.
“There’s no one-size-fits-all here,” says Gerry Wedig, a professor and health care economist with the Simon School of Business at the University of Rochester. “It’s a complex law designed to further regulate a very fragmented market.”
You don’t hear about Obamacare much during prime-time TV. But what if art imitated real life and Walter White took a break from “cooking” to look for coverage for his family, or the “2 Broke Girls” were worried about the individual mandate—the requirement starting in January that practically every American must have insurance or face a penalty?
To help explain some of the key changes under health insurance reform, we’ll take a look at familiar television characters representing the different ways American are affected by the law.
Walter White from ‘Breaking Bad’
Teacher-turned-meth-maker Walter White (Bryan Cranston) fights many battles on AMC’s “Breaking Bad”—including with cancer. Such a pre-existing condition would put him among the “big winners” under Obamacare, says health economist Marjorie Baldwin of the W.P. Carey School of Business at Arizona State University.
“If someone with a pre-existing condition was previously denied health insurance coverage or unable to afford coverage, then that person will now be able to purchase insurance at more affordable rates,” she notes. “Also, people with chronic health issues who had been paying high rates for coverage on the individual market will likely see a drop in premiums.”
There’s an additional advantage for Walt’s son, Walter Jr., who suffers from cerebral palsy, a costly lifetime condition.
“The lifetime (health insurance) caps are going away next year,” says Wedig. “That’s a very big deal for people who have chronic conditions because it means they won’t run out of coverage.”
A 2009 report from consulting firm PricewaterhouseCoopers found that approximately 55 percent of individuals with employer-sponsored health insurance were subject to lifetime limits. Those limits were typically $1 million or $2 million.
Haley Dunphy from ‘Modern Family’
The bad news is that Haley Dunphy had to drop out of a college away from home and is now back in her old bedroom, attending community college. The good news is that Haley—Phil and Claire Dunphy’s older daughter on ABC’s Emmy Award-winning “Modern Family”—will have a few more years on her parents’ health insurance thanks to Obamacare.
Since 2010, the Affordable Care Act has allowed adult children to stay covered through Mom or Dad until age 26.
“Children can join or remain on their parent’s plan even if they are married, not living at home, attending school, not financial dependents or eligible for an employer’s plan,” says Lisa Zamosky, health reform expert with the medical information website WebMD.
She says the exchanges will make it possible for even more families to take advantage of the provision, as uninsured parents buy policies that will include their older children.
“Rates for family plans may increase because of the expanded coverage to 26-year-olds,” notes Baldwin, “but not by much because this is a fairly healthy demographic group with low health care costs on average.”
The Gallaghers from ‘Shameless’
Fans of Showtime’s dark comedy series “Shameless” know that the Gallagher family, like the more than 46 million Americans living in poverty, can barely afford basic necessities, let alone health insurance.
Obamacare had intended to cover the poor through an expansion of the Medicaid system. But that plan hit a bump in the road when the US Supreme Court ruled that states could opt out of the expansion. So now, “The Medicaid expansion is going to vary depending on where you live,” says Wedig.
Twenty-three states and the District of Columbia have agreed to boost Medicaid coverage, but 21 have said no, and six are undecided.
The Gallaghers live in Chicago, which is in one of the expander states (Illinois).
Low-income people in nonexpansion states can request an exemption from the individual mandate based on financial hardship.
“Ironically, people with incomes from 138 to 400 percent of the poverty line are eligible for subsidies to purchase insurance through an exchange, but people with incomes from 100 to 138 percent are not,” says Baldwin. “They were supposed to be covered by Medicaid. But in states that do not expand Medicaid coverage, these people are the big losers after the Supreme Court ruling.”
The crew from ‘The Newsroom’
It’s probably safe to assume that Will McAvoy (Jeff Daniels) and the rest of the journalists at ACN, the fictional cable news network in HBO’s “The Newsroom,” already get coverage through their employer, which is the case for most Americans.
Nearly 60 percent of Americans younger than 65 have health insurance through work, according to the Employee Benefit Research Institute, an independent think tank.
Some economists, such as Baldwin, believe insurance costs will rise next year for most employers and their workers as insurers cope without lifetime caps and without being able to deny coverage for pre-existing conditions. Plus, she says, as Will and other baby boomers age and medical technology gets pricier, workers may pay even more through higher premiums, employee contributions, copays and deductibles.
Down the road, employers like ACN also may cut coverage to avoid the tax on so-called Cadillac plans, says Wedig. Beginning in 2018, plans that cost more than $10,200 for an individual or $27,500 for a family will draw a 40 percent excise tax on the amount over those limits.
“Whether it’s next year or a few years from now, people with those plans will see a combination of higher costs or decreased benefits,” Wedig says.
The ‘2 Broke Girls’
Hourly small-business employees, such as the staff at the Williamsburg Diner in the CBS show “2 Broke Girls,” may not get much leverage from Obamacare if they’ve been lacking health coverage through work.
“This situation is actually quite clear under the law,” says Zamosky. “Employers with fewer than 50 (full-time) employees are under no obligation whatsoever to offer health insurance.”
Their employer could choose to buy the girls coverage through the exchanges and possibly even get a subsidy, Wedig says.
On the other hand, if the diner already provides health insurance, it could opt to drop the coverage, forcing them to shop for their own health plan or pay the individual mandate penalty.
But if the diner offers health insurance and chooses to keep it, Baldwin says the rates could go up because the law requires small-business plans to offer a new set of essential health benefits including emergency services, hospitalization, and maternity care. The girls may get better coverage but it would likely mean an increase in their employee contributions.
“Either way, the girls are likely to be even more broke,” says Baldwin.
The telemarketers on Comedy Central’s “Workaholics” are the type of workers who could end up in limbo, assuming their employer doesn’t offer coverage.
Obamacare requires businesses with at least 50 full-time employees to provide health insurance, but that “employer mandate” has been delayed until 2015. So uninsured workers will have to decide whether to buy their own insurance for 2014 or pay the individual mandate penalty.
“The tax penalties in the first year will be less than the cost of health insurance on the exchange (the greater of $95 or 1 percent of taxable household income), so many of the uninsured on ‘Workaholics’ may decide to pay the penalty and wait one year to get employer-sponsored insurance coverage,” says Baldwin.
But their employer may choose not to offer coverage in 2015 and pay the employer mandate penalty of up to $3,000 per worker.
“That may not be a huge hit for a large company compared to the cost of providing coverage,” says Judy Bradby, founder of ProHealth Strategies, a health care consulting firm in Hampton Roads, Va.
There’s been speculation that large employers may cut full-timers because the law doesn’t require coverage for part-time employees averaging less than 30 hours. Next
Elka Ostrovsky from ‘Hot in Cleveland’
Senior citizens such as Elka Ostrovsky, Betty White’s sharp-tongued character on TV Land’s “Hot in Cleveland,” have gained benefits from the Affordable Care Act, says Zamosky.
Some of those benefits come in the form of increased services, such as preventive care. Under the Affordable Care Act, Medicare covers mammograms and colonoscopies with no out-of-pocket costs, and one annual wellness visit is free. And the law will eliminate the so-called doughnut hole—the gap in prescription drug coverage that has left seniors paying full price for their drugs at certain spending levels.
“The law is slowly closing the doughnut hole,” says Zamosky. “By 2020, the discounts will grow to 75 percent, leaving seniors to pay just 25 percent of drug costs.”
“Next year, Medicare will look about the same for most seniors,” Wedig says. “But as the health care system adapts to Obamacare, Medicare will likely also adapt.”
He says seniors should understand that the hype and scare tactics surrounding Medicare dwarf any actual concrete changes to the program under Obamacare.
Frank Underwood from ‘House of Cards’
Representative Frank Underwood, the fictional, conniving congressman played by Kevin Spacey, may be preoccupied with revenge in the Netflix political drama “House of Cards.” But experts say he ought to give some thought to his new health insurance.
“The law requires members of Congress and congressional staff to obtain their health insurance through the health insurance marketplaces,” says Zamosky.
With Washington, things are never simple. Obamacare’s insurance for members of Congress, who previously enjoyed excellent coverage with a lot of options, has been the subject of much speculation. It has been unclear whether the law allows the federal government to contribute a portion of the premiums for lawmakers and their staffs, the way private employers do.
Under the current congressional health insurance plan, the government pays up to about $5,000 a year for individual coverage and $11,000 for a family.
The administration has proposed that the government continue to pick up that tab and let lawmakers decide whether their staffers must buy coverage in the Obamacare exchanges.
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