Before the Affordable Care Act (ACA) went into effect in 2014, millions of people lived without health insurance. Most of the uninsured were people below age 65 and above age 18 (nearly all people above age 65 are covered by Medicare, and many states offer health insurance to qualifying children). “Before ACA began, about 50 million people in the U.S. were uninsured—almost one in five nonelderly adults,” said Dr. Donohue. “ACA isn’t intended to be universal care. We knew that, even with requiring everyone to have health insurance, not everyone would participate. ACA is meant to fill the serious gaps in coverage.”
According to Dr. Donohue, the largest risk factor for being without health insurance is having a low income—at or near the federal poverty level. “Many people who are working full-time in a low-wage job are right around that poverty line. And, even if you were poor, you wouldn’t necessarily qualify for programs like Medicaid prior to ACA.” People in racial and ethnic minority groups also tend to be at higher risk for lacking health insurance coverage.
The health insurance landscape, however, has changed a lot in the past few years. Politicians have argued about the perceived costs of ACA, whether health insurance should be required and many other concerns. But, said Dr. Donohue, “There has been so much negative attention paid to ACA. It’s easy to lose sight of the fact that this legislation has created new opportunities for people to gain coverage, improve financial security and improve their health. Employment-based health insurance works really well for the 165 million people who have it. But lots of people lose their jobs, have jobs that don’t come with health insurance or want the flexibility to leave their jobs without losing their coverage. I would encourage people to look past the politics and look at the coverage avail
able.”
Dr. Donohue recommends that people who are interested in health insurance coverage start by going to https://www.healthcare.gov. ACA set up two new sources of coverage (one new and one an expansion of an existing source of coverage). Healthcare.gov is what’s known as the insurance exchange or marketplace. This is a website where people can set up an account. After they enter some basic information, like where they live and their income, they can find out what plans are available to them and at what cost. There are private health insurance plans like UPMC and Highmark and big national companies like Aetna and United that offer products with different monthly costs and benefit packages.
Dr. Donohue also points out that the majority of people getting coverage through these marketplace plans aren’t paying 100 percent of the cost themselves. They are getting help from the federal government. Cost is on a sliding-scale basis. The subsidies begin at incomes at 100 percent of the federal poverty level (which is $11,770/year for individuals and about $24,250/year for a family of four, according to the U.S. Department of Health and Human Services) and go all the way up to people at 400 percent of the poverty level (those with incomes in the $90,000 range) getting at least part of their monthly premium offset through a tax subsidy. If people’s income is below 138 percent of the federal poverty level, they could be eligible for Medicaid if they are in a state like Pennsylvania that has decided to expand its Medicaid coverage (which just started in 2015).
The annual open enrollment period starts November 1. But if people’s circumstances change outside of the enrollment period—they lose their jobs or coverage—they do not have to wait until next November to enroll. They can enroll immediately. For more information about enrollment, go to www.enrollamerica.org.
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