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Wayne Post
  • THE AFFORDABLE CARE ACT: How health reform will affect you

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  • When Ross Freida was 19, he broke his nose. Not a life-threatening condition to be sure, but without health insurance — because he had been removed from his parents’ insurance at age 18 — paying for treatment was a big deal.
    Flash forward. Freida, now 25, is married with children and —as a union pipefitter and welder — has health insurance for his family through work. Ross’s mom, Mickey Freida, a kindergarten teacher, and his dad, Ron, an assistant business manager for Local 86, an electrical workers’ union, are also in good shape with insurance.
    The two generations of the Gorham family aren’t worried about paying for health care at the moment. But, said Mickey, not everyone is so fortunate. Thinking of those months her son didn’t have insurance, Mickey said she has high hopes for what the new health care law can mean for the community.
    “No one should have to be without insurance,” she said.
    Ross said he never gave health insurance much thought — until he needed it. “It never occurred to me until I got hurt,” he said.
    The promise
    On Oct. 1, people can begin enrolling in health insurance plans that take effect Jan. 1, 2014, through a new marketplace called the Exchange. New York State of Health, as the Exchange is called in New York, can be used by individuals, families and small businesses with 50 or fewer employees. It offers a wide variety of health and dental plans and providers. It’s the place to shop, compare and enroll in a low-cost quality plan that is right for you. It’s the only place you can receive financial assistance based on your income, to lower your costs even more.
    “We encourage everybody to look at the Exchanges,” said Ianne Poushter, account coordinator with Benefit Specialists of New York (BSNY). Poushter offers one-on-one consultations and is the go-to person for members of the Canandaigua Chamber of Commerce.
    “This is the really big year and it really is all about the Exchanges,” said Lynne Scalzo, vice president for business strategy and health care reform at Excellus BlueCross BlueShield. Coverage that now costs at least $1,000 a month for one person can be greatly reduced, said Scalzo.
    By Jan. 1, everyone must have health coverage, according to the new federal law’s so-called individual mandate. Tax subsidies will make premiums more affordable for those with lower and middle incomes.
    For people seeking coverage through the Exchange, federal assistance in paying for premiums will be available for people up to 400 percent of the federal poverty level. That is $45,960 per year for an individual and $78,120 for a family of three.
    The only folks not needing the Exchange are those on Medicare and those offered affordable insurance through their employer.
    “The most affected will be, to me, the uninsured,” Scalzo said. “This is an opportunity for them to have affordable coverage that wasn’t available to them before in New York state unless they were the very lowest income. … It fills a pretty big gap.”
    Page 2 of 3 - According to a report released this year, the uninsured rate in Ontario County between 2009 and 2011 was 8.8 percent, compared to 8.2 percent for the entire Finger Lakes region. The rate overall for New York state was 11.6 percent, while the national rate was 15.2 percent, according to the report by Excellus BlueCross BlueShield based on data collected by the U.S. Census Bureau’s American Community Survey.
    The details
    Steph Larsen is assistant director of organizing with Center for Rural Affairs, a national organization that advocates for rural areas involving federal policies. She answered the following questions that cover main points frequently asked.
    Q. Why should you buy insurance from the marketplace?
    A. Private insurance plans sold in the marketplace will be easy to compare. They’ll all be written in simple language, and you’ll be able to see which one is best for you. It is also the only place to get federal subsidies to help make private insurance affordable.  
    Q. How can you say the marketplace will be affordable?
    A. If you are below 400 percent of poverty ($94,000 for a family of four), the maximum you will pay for your health insurance is 9.5 percent of your income. The rest will be paid by a federal subsidy.  
    Q. What if I have a “preexisting condition?"
    A. In the marketplace, insurance companies will take everyone. No rejections, no health questions, no checking your medical records. You’ll get charged the same as everyone else with a similar age, location and family size. And the same federal subsidies will apply, to help keep it affordable.  
    Q. Can I keep the insurance I have now?
    A. Yes, you’re free to purchase any private insurance you choose or stick with insurance your employer provides. But it will have to meet some minimum standards of coverage. As it stands now, and in general, if your employer offers you comprehensive, affordable health insurance, you cannot purchase on the health insurance marketplace. If you have to pay more than 9.5 percent of your household income towards the premium, it is considered unaffordable and you or your family could purchase at the marketplace.
    Irene Coveny, director of Ontario County Office for the Aging, emphasized that the new law does not affect those on Medicare.
    “The health Exchanges are not for people with Medicare,” said Coveny. The new marketplace will not affect their Medicare coverage, she said.
    She advised those on Medicare that if someone from a health plan tries to send them to the marketplace (Exchanges), “they should not be sold.”
    Coveny said a big marketing blitz for the Exchanges is coming soon this fall and as it overlaps with the open enrollment period for Medicare, it adds to the confusion. Office for the Aging is available to answer questions and keep people on the right track with their choices, Coveny said.
    Page 3 of 3 - The challenge
    Eileen Tiberio said the new law emphasizes prevention. It focuses on screening for various health conditions and, overall, avoiding health problems by making sure everyone has insurance and can afford to seek preventative care, as well as treatment for existing ailments and catastrophic conditions.
    Whether it will work the way it is meant to remains unclear, she said. Meanwhile, predictions abound.
    “I have heard the gamut,” said Tiberio. “From the sky is falling to everything is OK.”
    Tiberio shares a concern that others in the health and social services fields have: How will the system handle the influx of new patients?
    “Coverage is one thing, but providers are another,” she said. “Will there be enough providers and enough of the type of providers needed?"
    “There are not enough doctors to go around now,” said Dr. Robert Ostrander, a co-founder in 1994 of Valley View Family Practice Associates, which has offices in Rushville and Canandaigua. Ostrander is one of three physicians at the practice that provides a full scope of family care including routine obstetrics, office surgery, hospital care for adults and children, and surgical assisting for major surgery for the rural community.
    If the exchanges work, those who previously went without insurance or who couldn’t afford to go to a doctor for any reason will be better off, said Ostrander: “Medical care will be better for them.”
    That is if they can find a doctor and get to see that doctor in a timely manner, he added.
    Ostrander said he foresees “the primary care system overwhelmed” and he sees nothing in the new law to address “getting people into the pipeline quickly.”
    “There’s a lot of uncertainty,” said Tiberio. “We just don’t know what it will look like … it’s all still up in the air.”
    — Includes reporting by the (Utica) Observer-Dispatch

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