By Laurence Hammack and David Ress
Over the course of five years, Charlene Humphrey’s kidney stone has grown to nearly the size of a walnut, demanding an operation she cannot afford.
Humphrey makes $9.25 an hour working the front desk of a Christiansburg motel. While it’s not enough to pay for health insurance, Humphrey does not qualify for Medicaid, the government health program for the poor.
Not long ago, Humphrey’s doctor warned her that without surgery, her left kidney could become infected and shut down.
“It’s kind of like I’ve got a ticking time bomb inside my body,” she said, “and I have no idea when it might go off.”
Humphrey — who like many working-class Virginians has lived without health insurance for much of her life — is one of many who would benefit from a government program to make private insurance more affordable with subsidized plans available through an online marketplace.
Under the Patient Protection and Affordable Care Act, people with incomes between the federal poverty level ($11,490 for an individual, $23,550 for a family of four) and four times that level will qualify for subsidies.
Participants will be able to go online and shop for the best coverage, much like someone booking an airplane flight would browse the websites Expedia or Orbitz.
But if searching for flights, juggling departure times and accounting for hidden airfare costs seems complicated, shopping for insurance could be even more so.
Many details about premiums, out-of-pocket costs, benefits and which doctors, hospitals and drugs the plans will cover remain up in the air, less than three months before enrollment is scheduled to begin Oct. 1.
This much is clear: Each state will have its own marketplace, also known as an exchange. They are a key part of a sweeping overhaul of the country’s health insurance system, still on track despite a recent one-year delay in a requirement that employers with more than 50 full-time employees offer insurance or face financial penalties.
All of the exchanges will follow the same federal formula, offering subsidies on a sliding scale based on income, with the greatest savings going to the poorest applicants.
Even if Virginia decides to expand Medicaid, as called for by the Affordable Care Act but by no means a certainty, Humphrey would not be eligible for that program. Her annual salary of $19,000 is slightly above the eligibility cutoff.
“I think it’s incredibly unfair,” she said of her current inability to afford health care.
A subsidized insurance plan through the marketplace could be her only hope for coverage — and for surgery to remove her staghorn kidney stone before it’s too late.
Humphrey also suffers from diabetes, high blood pressure and high cholesterol. She gets some help from free clinics and Carilion Clinic’s charity care program, but she still must juggle the medical bills with the costs of other essentials, such as food and the small cabin in northwest Roanoke that she rents from a church.
“There’s a really big gap there for people who can’t get the help they need — basic medical care,” she said.
A lot of questions
At a recent seminar in Roanoke, Beth Maiden had the daunting task of explaining how the Affordable Care Act will play out in Southwest Virginia.
Maiden, a client executive with BB&T Insurance Services, described how Virginia will use an insurance marketplace run by the federal government, rather than create its own as some states are doing.
People who want to buy insurance on the marketplace can sign up starting Oct. 1 for plans that will become effective on the first of next year, she said. As for the details, she didn’t have many.
“We are just a few short months away, but we are all scratching our heads and saying: ‘What are these exchanges going to look like?’ ” Maiden told the small crowd gathered at the Roanoke Higher Education Center.
U.S. Rep. Morgan Griffith, R-Salem, who will be among the people shopping for coverage on the exchange, also finds it confusing. (Although the Affordable Care Act requires members of Congress and their staff to use the marketplaces, they will not qualify for subsidies.)
“Button, button, who’s got the button; exchange, exchange, who’s got the exchange?” Griffith said, referring to the traditional children’s guessing game. “We can’t tell what is the exchange going to have.”
Part of the uncertainty stems from the massive task, currently being undertaken by the federal government, of building a so-called “data hub” that will serve as a conduit to the state marketplaces.
The data hub will be used by the exchanges to verify an applicant’s income and other information, which is needed to determine what kind of subsidy they qualify for. That will entail tapping into records compiled by about a half-dozen agencies, including the Internal Revenue Service and the Social Security Administration.
Whether the system will be ready by Oct. 1 is questionable, said Dan Schuyler, a director at Leavitt Partners, a health care intelligence firm that is assisting nearly a dozen states with their marketplaces.
“There is a calculator, if you will, to determine what the subsidy levels will be,” Schuyler said. “It’s the verification process that is up in the air.”
Several critical tasks, including final testing, have yet to be completed, according to a June 19 report by the U.S. Government Accountability Office, the investigative arm of Congress.
Whether the system will be up and running smoothly by the open enrollment date “cannot yet be determined,” the report stated.
Schuyler said it’s possible there will be a lag time of several weeks, rather than the real-time verification of information envisioned by the law. Another possibility is that the process will be completed on paper — which had been planned only as a backup for those without access to a computer — while the kinks are worked out.
Timothy Jost, a law professor at Washington and Lee University and an expert in health care law, said a short delay should not cause problems.
“If on Oct. 2 they announce it’s going to take another five days to get it running, I’m sure the Republicans will say the sky is falling … but frankly it won’t make any difference,” Jost said.
Enrollment will continue through the rest of the year, and as of last Wednesday the government was saying the marketplace was still on schedule to open Oct 1.
A marketplace run by the federal government will be used by 27 states, according to the Kaiser Family Foundation. Another 16 states and the District of Columbia are building their own systems. Seven states are partnering with the federal government.
In Virginia, the mechanics of running the marketplace will be left to federal officials while the state will monitor the insurance companies that sell plans through the system.
Total dependence on the federal system could be risky, Schuyler said.
“You’re getting this gray box, if you will,” he said. “And if you have an issue with it, you have to call the federal government.”
Costs headed upward
Some of the most important pieces of information that people will need in order to shop for coverage — details on monthly premiums, deductibles, copayments — are still under review by the State Corporation Commission’s Bureau of Insurance.
One theme emerging from the thousands of pages of paperwork filed by insurers is that there likely will be healthy competition to attract the Virginians who don’t have coverage now, said Doug Gray, executive director of the Virginia Association of Health Care Plans.
Four companies — Aetna Life Insurance, Anthem Blue Cross and Blue Shield’s HealthKeepers, Coventry Health Care and Optima Health Plan — have told the bureau that they plan to offer coverage in the Roanoke Valley and most of the New River Valley. There will be four firms chasing business in Bedford County, three in Botetourt and Floyd counties, and two in Alleghany County and most of the rest of Southwest Virginia, except for Grayson and Lee counties.
The filings suggest that health plans see widely varying prospects and risks.
They do agree, however, that the basic trend in medical costs is that they are likely to outpace inflation, with increases ranging from 6 percent to 10 percent.
Carriers expect an even bigger cost increase — roughly double the hit from rising drug prices, doctors’ fees and hospital charges — from the new customers signing up for coverage through the exchange. One reason is that the Affordable Care Act says insurers can no longer turn people down because of poor health, a practice known as “health underwriting” in the insurance business.
On top of that, insurers are looking for as much as a 10 percent boost in costs from pent-up demand that will come from newly insured people seeking treatment they’d postponed because they had no coverage.
All of those factors will go into determining the premiums that insurers will charge. The bureau needs to make sure those premiums will generate enough money to pay for claims.
The bureau expects to finish its work several weeks before Oct. 1 so consumers will have a chance to see what their premiums will cost, and balance that against the cost of deductibles and co-payments.
The stakes are high.
“If you’re going to offer richer benefits and health underwriting is going away, if you’re an insurer you’ve got to figure out how you’re going to afford that,” Gray said.
Supporters of the marketplace say that spreading the costs among a larger group of healthier people will make coverage for the uninsured more affordable. They also argue that subsidies from the federal government, countered by savings from other parts of the Affordable Care Act, will help balance the books.
Critics don’t see it that way.
Rep. Bob Goodlatte, R-Roanoke County, thinks consumers’ insurance choices will shrink on the exchanges. He shares Griffith’s concern about how implementation of the plans is moving.
Dave Schwartz, Virginia director of Americans for Prosperity, a conservative advocacy group, said the system will drive up costs for all consumers.
“You’re bringing in a pool of folks with pre-existing conditions … insurance companies and government will now have to pay for expensive procedures for folks who didn’t have coverage,” he said.
“There’s not going to be enough people to make up for that.”
$300-$325 a month
Assuming all goes as planned, someone who visits the website healthcare.gov on Oct. 1 in Virginia will find four basic levels of coverage: bronze, silver, gold and platinum.
The plans will differ in their requirements for co-payments, or the share of a bill that a patient pays, and deductibles, the amount a person pays before the insurer starts covering bills. The networks of doctors, hospitals and clinics available could differ. There could be differences in the kinds of procedures or medications or medical devices covered. Premiums will vary, with lower monthly costs attached to plans that require higher out-of-pocket spending from patients.
None of that information is generally available now.
But overall, health plans expect that people in the Roanoke area who buy coverage through the marketplace will pay about the state average for exchange-based plans, according to their filings. For a nonsmoker in his or her 40s, that’s in the $300 to $325 a month range, the documents show.
Rates will be slightly higher than the state average in the New River Valley.
For someone like Humphrey, making $19,000 a year, those rates amount to a heavy burden — about 20 percent of her income before taxes.
That’s where the Affordable Care Act subsidies come in. Under the law, someone with an income that’s 65 percent above the poverty line, as Humphrey’s is, should not have to pay more than 4.7 percent of her income for a middle-of-the-road silver plan. That’s $74.50 a month.
“That sounds pretty good,” said Humphrey, who would have to pay about $300 a month for coverage through her employer.
Her subsidy would be based on the difference between the $74.50 and the actual premium for a silver plan, which is still unknown at this point. With that subsidy, she also could opt to save on her monthly premium by choosing a bronze plan with its higher deductibles and co-payments. Or she could decide to spend more each month on premiums for a gold or platinum plan in order to hold down her out-of-pocket expenses.
Annual out-of-pocket expenses are capped — for Humphrey at $2,250, while for people with incomes greater than 250 percent of the poverty line, the cap will be $6,350.
As many as 870,000 people in Virginia could be eligible for subsidized coverage, U.S. census numbers suggest. Small businesses would also be allowed to purchase plans for their employees through the marketplace.
‘I don’t want anything for free’
When Humphrey’s back began to ache several months ago, she first thought it was yet another new ailment.
After a visit to the doctor, she learned the problem was linked to her kidney stone.
Humphrey, 42, went to a free clinic for help, only to learn that she would still have to pay for her anesthesia and hospital stay.
At the time, she was about $20,000 in debt, living off food stamps and a job that paid just a little more than the minimum wage.
“My bills are really stacking up right now,” she said last month.
As a taxpayer who has worked all her life, Humphrey believes a government-subsidized insurance plan is not too much to ask for.
“It’s not like I want to sit back and let the government take care of me,” she said.
“I don’t want anything for free. I just want to be able to afford the care I desperately need.”