Wanted: User manual for health care overhaul

[March 23, 2010]  WASHINGTON (AP) -- President Barack Obama and the Democrats have overcome their doubts and divisions to pass landmark health care legislation affecting every family and one-sixth of the economy. The president will sign the main bill at a White House ceremony scheduled for Tuesday, and a companion package of fixes is expected to be on its way to his desk soon.

That leaves Americans with a burning question: How's this all going to work?

"A key element to these reforms is that options that weren't available to people will become available now," said DeAnn Friedholm of Consumers Union. The publishers of Consumer Reports supported Obama's effort.

Some questions and answers on the health care bill:

Q: When are the uninsured going to get coverage?

A: Most will have to wait until 2014.

That's when the government begins providing tax credits to help people who can't otherwise afford to pay health insurance premiums. The aid will be available on a sliding scale to households making up to four times the federal poverty level, or about $88,000 for a family of four.

A four-person family making around $40,000 will pay only about 5 percent of its income. But the same size family making $80,000 will pay nearly 10 percent of its income. Medicaid will be expanded to cover people up to 133 percent of the poverty level, or about $29,300 for a family of four.

Starting that same year, health insurance companies would have to take all applicants. They could not deny coverage to people in poor health, or charge them higher premiums.

More than 30 million people will gain coverage, and by 2016 about 95 percent of eligible working-age adults and their families would have health insurance. Most would buy their coverage through health insurance exchanges, new state-based purchasing pools. Illegal immigrants wouldn't be able to participate.

Q: So after all the ruckus, nothing happens for another four years?

A: Not at all. There will be plenty of changes before the big push to expand coverage.

For example, the bill starts to close the gap in the Medicare prescription drug benefit right away. Seniors who fall into the dreaded "doughnut hole" gap in coverage will get a $250 rebate this year.

Other changes starting this year include prohibiting health insurance companies from canceling coverage if you get sick, and banning lifetime dollar limits on coverage. Insurers also would be prohibited from denying coverage to children because of a pre-existing medical condition.

In a big change for middle-class families with kids in college, parents will get to keep adult children on their health plan until they turn 26.

Q: That might help kids moving from college to work. What are the requirements?

A: The main requirement for now is that adult children not be eligible for workplace insurance of their own.

The Senate bill originally also required them to be unmarried, but the House has voted to lift that restriction, and the Senate is expected to follow. (Grandkids, however, would not be eligible.)

To what degree adult children would have to be financially dependent on their parents remains to be clarified in regulations. However, congressional staffers involved in writing the legislation said lawmakers did not intend to require that parents have to support their kids to keep them on their coverage.

Q: Twenty-year-olds are usually pretty healthy. What if you're uninsured right now and you also happen to be sick?

A: There's a transition program in the legislation meant to help the most vulnerable.

Until 2014, when insurers have to take all applicants, the government will pump money into high-risk insurance pools that many states already have set up and others are planning to establish. That would allow the states to offer coverage to people no commercial plan will accept.

There's a catch, however. Although Obama has allocated $5 billion for the program, most experts say that's nowhere near enough to last four years.

Q: Seniors have been wary about the Medicare cuts that will help finance Obama's overhaul. Have the Democrats done anything for them?

A. Closing the prescription coverage gap is a tangible benefit for seniors. After this year, the gap will be reduced gradually through a series of discounts for brand name and generic drugs. By 2020 seniors will pay the standard 25 percent coinsurance for their prescriptions.

Other improvements include a new emphasis on prevention in traditional Medicare, as well as efforts to better coordinate care for patients struggling with several chronic conditions, like the common combination of high blood pressure, diabetes and heart problems.

But the Democrats also are cutting a popular Medicare program, private insurance plans that serve about one-fourth of seniors. Until now, the plans have gotten generous payments from the government, allowing them to offer lower out-of-pocket costs and other benefits. Scaling back the subsidies to Medicare Advantage plans could prompt an exodus of seniors back to the traditional program.

Q: Does the plan require employers to offer coverage to their workers? And what about individuals? Does everybody have to have insurance? Can Congress do that under the Constitution?

A: Employers aren't required to offer coverage, but companies with more than 50 workers could be hit with hefty fines if just one of their employees gets government-subsidized coverage. (The plan provides tax credits to help smaller companies get and keep coverage for their employees.)

Individuals would be required to carry health insurance, either through an employer or a government program or by buying it themselves. Those who refuse would get fined by the IRS.

Many legal experts say Congress does have the power under the Constitution to require coverage. But that issue is likely to be settled in court.

[Associated Press; By RICARDO ALONSO-ZALDIVAR]

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