Obamacare Comes To NYC, NYS & America
NYC Prepares For The Affordable Healthcare Act
Update - Over 197,000 New Yorkers Have Completed Applications of which over 48,000 have already selected and enrolled in a plan. Over 142,000 people were helped by the New York State of Health which runs the health plan marketplace for New York State. Note that open enrollment for the tax year 2014 ends on March 31, 2014.
I just returned from the United Civic Community Association [UCCA] sponsored forum on Obamacare at the Museum of the Moving Image. The forum did a nice job of providing what appeared to be a good summary look into what the federal government’s Affordable Healthcare Act [also known as Obamacare] is really all about.
The forum was moderated by Rose Marie Poveromo, President of the United Community Civic Association of Astoria and included a panel of experts. The panel included U.S. Congressman Joseph Crowley, Rebecca Jackson, a NY State of Health Project Coordinator, Caryn Schwab Executive Director of Mount Sinai Queens, Judy Trilivas Chief Operating Officer of Mount Sinai Queens and Minna Elias Congresswoman Maloney’s Chief of Staff. They are shown seated from left to right in the photo above, at the UCCA hosted Obamacare Forum at the Museum of the Moving Image in Astoria.
Click here to read more about Obamacare comes to America NYC NYS.
Obamacare Comes To NYC, NYS & America
NYC Prepares For The Affordable Healthcare Act
I arrived about a half hour into the three hour forum. Two of the five panelists had already given their brief presentations prior to the forum being opened to the crowd for Questions and Answers [Q&A]. I’m pretty sure what I missed was rehashed in the Q & A session which was allocated the bulk of the time.
Mount Sinai Queens Hospital - Shared Sacrifice To Provide 44 Million Americans With Preventative Healthcare
Caryn Schwab was speaking as I settled in. She commented that providing tens of millions of people in America affordable healthcare was a good thing, even though the entire healthcare system is going to have to make major adjustments to accommodate them. She told us that while the volume of insured people participating in the healthcare system is expected to rise, thus bringing in more revenue; reimbursement to hospitals for patients will be reduced. The result is that Mount Sinai Queens expects an overall reduction in revenue.
She also cited that incentives built into the Affordable Healthcare Act designed to help healthcare institutions like Mount Sinai Queens move to electronic record keeping systems, was already providing proving useful with resepct to the quality and efficiency of the Mount Sinai Queens operation [this is true for all companies making this change]. The new electronic systems make information accessible and accurately transferable instantly.
Rationale For The Affordable Healthcare Act - Obamacare in Queens
Minna Elias of Congresswoman Maloney’s NY Chief of Staff gave us her ‘Top Ten’ of how Obamacare will help. She told us that:
1) you’ll never have to pay higher premiums for pre-existing conditions and you cannot be denied insurance [she noted that oftentimes C-sections and domestic violence were considered pre-existing conditions by insurance companies],
2) children may remain on their parents insurance plans until age 26 [this was implemented several years ago when the bill first passed],
3) no gender rating - she told us that women have had to pay 40% higher premiums in some instances,
4) this law closes the loop for the Medicare Part D Loophole by the year 2020 [this has something to do with Medicare not paying for self administered drugs],
5) Obamacare completely covers ‘wellness visits’ without any copay or deductible payments [this means you can get an annual check up / screening tests for free],
6) it expands preventable healthcare services for Medicare seniors [eg. cancer screening at no additional cost],
7) insurance ‘caps’ have been eliminated [it used to be that insurance companies ‘capped’ the total value of benefits an individual could receive],
8) insurance companies are not allowed to make ‘excess profits’ meaning that 85% of their revenue must go directly toward the provision of healthcare services,
9) you cannot lose your insurance if you’re sick, and
10) 44 million Americans who didn’t have insurance will have it in the year 2014.
With that we went to Questions & Answers. Please note that I didn’t focus on citing who provided the answers, as much as on the answers themselves. See the roster of panelists in the introduction to this story.
Mount Sinai Queens New Building In Astoria Will Be Designed For The 21st Century
Mount Sinai is opening a new building in 2016. Given that the intent of Obamacare is to push people to preventative and out patient healthcare, versus the current reactive / hospitalization healthcare, does it make sense to complete this building?
Caryn Schwab said yes it does make sense, but not because more people who enter the Emergency room will be insured. The new building is going to be built to accommodate the intent of the Affordable Healthcare Act, by creating facilities that are designed to provide preventative and specialty healthcare services. The focus will be to keep people healthy by identifying problems early rather than seeing patients at a late stage in their disease or illness.
Congressman Joseph Crowley Talks About Obamacare In Queens
Joseph Crowley said that DISH – Disproportionate Share Hospitals – admit a far higher percentage of Medicaid patients who are lower revenue patients versus the norm. Inner cities take on this load, while more suburban or mid sized cities have less of it. He compared the Mayo Clinic in Minnesota to Columbia Presbyterian in NYC. Columbia Presbyterian has a patient population of which 27% is on Medicaid, while the Mayo Clinic has about 5% on Medicaid.
Because the Mayo Clinic’s patient population generally has access to a primary physician they spot issues earlier, catch them in phases one or two and thus have far higher success rates. Columbia Presbyterian’s population of Medicaid patients are admitted after they’re already in phases three or four and it’s difficult to play catch up and win … and thus it’s far more expensive and they have lower success rates as a result. It’s not reflective of the hospital, it’s reflective of the lack of preventative healthcare of the patients being admitted.
He also noted that undocumented workers generally do not have insurance and thus are examples of the phase three and four patients, because they don’t address healthcare issues until late in the game. Federal law doesn’t include undocumented workers in the Affordable Healthcare Act, but there are exceptions [children under age 19] and there are State options available to them such as Medicaid.
Obamacare Is 1st Real Attempt To Rein In Healthcare Costs & Provide Wider Access To Preventative Care
He also noted that this is the first real attempt to fix the broken American healthcare system. And reiterated Caryn Schwab’s statement earlier, that accommodating this large influx of citizens into the healthcare system is going to require shared sacrifice by providers and insurers, but that over time adjustments will be made.
Stats & Facts About The Current State Of Healthcare In America
[Editor’s Note: America spends FAR more per person on healthcare than any other nation in the world. In 2010 the U.S. spent $8,233 / person or nearly 18% of Gross National Product. The next closest nation, Norway, spent $5,300 / person. And yet the U.S. has fewer doctors as a percent of the population, fewer hospital beds per thousand of the population and provides fewer consultations per thousands of the population than most of the industrialized nations in our category. The U.S. also has the highest hospital spending per discharge [$16,708] by a long shot as the next highest cost per hospital discharge is Canada [$12,669].
The U.S. also has the highest prescription drug use [61%] and a whopping 25% of the U.S. is taking four or more prescription drugs daily. The U.S. population also pays almost 50% more for its prescription drugs than any other nation. And versus the rest of the world, Americans are consistently in the worst quadrant in terms of asthma, pulmonary disease, diabetes, and congestive heart failure. But the U.S. seems to fare better than average with regard to various types of cancer.
The net result is that we are #33 in the world for life expectancy at 79 / 76 years of age [females / males]. The longest life expectancy is in Japan at 83 / 79. The sources for this information are a study done by a non-profit, the Commonwealth Fund, and Wikipedia.]
Texas & Florida Government Officials Decide Their States Will Not Participate
Texas and Florida have decided not to participate and the Roberts Court has said that it is unconstitutional to legislate states' participation. Florida and Texas voters will have to pressure their legislators if they want access to the benefits of the Affordable Healthcare Act. In the Fall of 2013, the Tea Party wing of the Republican Congress lead an attempt to shut down the federal government to try to prevent the Affordable Healthcare Act from being implemented.
The Cost Of Opting Out Will Likely Cost Far More Than $95
It was also noted that individuals who opt out of the plan will have to pay a tax of $95 or 1% of income – whichever is higher. It was noted that many people only talk about the $95, ignoring the 1% of income and the whichever is higher. This penalty will rise to $695 per person or 1% of income by 2020. Rebates will be given to those with lower incomes. Income tax relief will be given to individuals making under $45,960 and a family of four making under $94,200.
New York State Health Insurance Exchanges - Info Access
New York State has twenty companies competing for business on the insurance exchanges.
One member of the audience said many poor and older people don’t have access to computers or don’t know how to use computers. Congressman Crowley said that printed materials are available through his office which they will send to constituents.
He provided his office telephone number 718.779.1400. And there are telephone operators standing by to help folks too. The toll free number for NY State of Health is 855.355.5777. This is the customer service number for official health plan marketplace for New York State. You can also talk to the Navigators who will give you in-person assistance through the whole application process free of charge. You can also talk to the participating insurance companies which are shown in a graphic further down in this report.
Caryn Schwab said that Mount Sinai Hospital Queens in Astoria also has printed materials available for the public.
Doctor Participation & Non-Participation In The Affordable Care Act
Congressman Crowley said that some doctors are opting out of Medicare because there’s not enough money paid through it. The law has factored in a sustainable growth rate in order to better compensate primary care physicians to entice them to participate in the plan. Initially this modification was estimated to cost about $200 billion in the course of the next ten years, but after making some tweaks, it’s now down to $165 billion.
See the Editor’s Note above regarding the U.S. need for more physicians. Congressman Crowley said that incentives are being put in place to increase the physician / nurse / medical technician population by 15,000 doctors over the next five years as they will be in high demand. Both the AMA and the Hospital Association are said to be supporting this effort.
Prescription Drugs, Medicare Part D & Obamacare In Queens
Someone asked about prescription drugs and Medicare Part D regarding new prescriptions and refills. On Medicare Part D there’s an approved list of drugs on the formulary and drugs not listed on the formulary are not available to patients. Oftentimes this is because doctors are instructed to substitute a generic drug for the name brand drug as in many cases they contain the same key active ingredients.
Patients have the right to appeal and reverse Managed Care companies on drug substitutions [generics for name brands], but not always. Congressman Crowley and Minna Elias [Congresswoman Maloney’s Office] said their offices would also help people make those calls. They said this is an imperfect method of handling this, but for now you can call them to help you get drugs listed on the formulary. Congressman Crowley provided his office telephone number which is 718.779.1400.
Is Out-Of-State Insurance Coverage Included In The Obamacare Plans?
Someone asked what happens when you sign up for a NYS exchange plan and then travel to another state and end up needing medical care in that state. We were told that just as in other managed care plans, the provider will outline what is considered ‘In Network’ benefits and what is considered an ‘Out of Network’ benefits. If you’re in doubt, call the Congressman’s office or you can also call the ‘Navigators’ or ask the insurance company before you purchase a plan.
The Obamacare Navigators In NYS, NYC & Queens
The Navigators are people who’ve been trained and certified by New York State to advise people / help them ‘navigate’ their way through the exchanges in selecting the right plan for themselves. The service is free of charge to citizens. Some of the exchange participants [insurance companies] use Aetna and Blue Cross / Blue Shield which have about 90% coverage in the U.S.A. So if you travel a lot and there’s some probability of needing healthcare out of state, look for this in the plan you select.
Click here for a list of NYS Health Insurance Exchange Navigators as of November 11, 2013.
First Real Attempt To Fix Healthcare In America & Disinformation
Congressman Crowley said the Affordable Healthcare Act will require fine tuning as people begin to use it because it’s complicated and it’s going to serve millions of people, but over time things will get worked out.
He also noted that there’s a lot of disinformation that’s been put out there by those who don’t want the plan to succeed. He noted that Republicans initiated 48 attempts to repeal the bill and tried to shut down the federal government to stop it, but they have not initiated even one attempt to try to modify or improve the plan.
Congressional members are required / MUST participate in the plan and exchanges. But they will participate in D.C. because that is where they and their families spend most of their time. The government, like many private companies, will pay for their insurance – but they MUST give up their current insurance and participate in the plan. He also said the Congressional members also pay into social security, which is something most people don’t know.
Affordable Healthcare Act Impact On Insurance Costs
One person asked if it was true that the Affordable Care Act will reduce insurance costs by as much as 50% in New York. We were told that it’s true for those who are self insured and not covered by a group plan, which is a very small percentage of the population.
It was noted that there will be tax credits for individuals earning up to $45,960 and up to $94,200 for a family of four. You, the taxpayer, can structure to obtain these tax credits immediately, or over time, or at the end of the year to help fund your participation in the exchanges. And the working poor will get help.
One aspect of the plan is that the New York State Insurance Fund will make sure costs are not raised by insurance companies nor by healthcare providers without real need. Insurance companies, as noted above, must spend 85% of their revenue on healthcare. It is also expected that the fewer uninsured the fewer excess premium plans required to provide benefits.
Obamacare Impact On Union Healthcare Plans - More To Be Done
It was noted that there are some union related issues regarding the plan, which the Administration will continue working to resolve. Unions supported the passage of the Affordable Care Act as it was seen as a good thing to provide 44 million more Americans with access to regular and quality medical care.
The focus of the Affordable Care Act [aka Obamacare] is on preventative healthcare. Hence there are no co-pays on annual check ups and many of the tests used to detect problems early.
Keeping Doctors, While Managing Their Concern With The Fee Structure
One woman said she wanted to keep her doctor and her doctor told her that to do so she would have to pay a ‘concierge fee’, meaning an extra sum of money because the doctor said the plans don’t compensate enough. These fees would not be tax deductible and are at the option of the patient, if the doctor decides to charge them and the patient doesn't opt for another physician.
Congressman Crowley said that doctors’ compensation was likely to be an ongoing issue which he expected would get resolved over time. He noted that the doctors were using their patients to get the message to legislatiors to increase their compensation for participating in the plan.
Insurance Companies & Healthcare Providers
Someone asked about what insurance plans hospitals, like Mount Sinai Queens, would accept. Currently insurance companies and healthcare providers negotiate deals with one another regarding inclusion in insurance plans and acceptance of insurance companies' clients. Sometimes the deals are exclusionary, such as Healthfirst working with Mount Sinai Hospital and North Shore LIJ Hospital, while not working with New York's Columbian Presbyterian Hospital. Generally part of these exclusionary deals are preferred prices given by the hospital to the insurance company.
Hospital Emergency Care Protocols In Queens
Caryn noted that all hospitals are required to accept you and treat you in a real EMERGENCY. But for less urgent care, both hospitals and insurance companies are free to choose who to work with. This means hospitals can decide what insurance to accept / not accept. She noted that currently Mount Sinai Queens accepts 98% of the insurance plans available to New Yorkers.
Doctor Participation In The NYS Exchange Plans
Provider Networks currently negotiate with doctors regarding participation in their plans and the fee structure. Under the Affordable Healthcare Act 9.5% of income spent on healthcare is considered affordable. [Editor's Note: As mentioned above Americans currently pay nearly 18% of income on healthcare and the cost of healthcare has been growing faster than income for most of the last 30 years.].
Residents' Tax Relief & Tax Incentives - Obamacare In Queens
As mentioned earlier in this report, many people will qualify for tax relief / subsidies to offset some of their healthcare costs, based on their income. The tax credits are manageable, meaning you can get immediate relief to help you pay for the healthcare insurance. You can also structure it so that you get some of the relief now and some at the end of the year. This scenario would make sense for someone whose income fluctuates.
If you're a Medicare user, you don't need to participate in the marketplace.
All Insurance Plans Have Been Certified In NYS Exchange
All insurance plans being offered through the NYS Insurance Exchange have been certified by New York State. One of the qualifying characteristics of each insurance plan is that the plan must have good primary care and specialist physician networks.
They are also planning to phase in a program called Healthy New York. Healthy New York is designed by the NYS Department of Financial Services in collaboration with HMOs and other insurance companies to provide affordable healthcare to individuals, proprietors and small businesses. Their website has been down lately, but when it comes back up it is:
And here's the link to NYS Insurance Exchange, which we've periodically checked and seems to be operating nicely.
Insurance Premiums - The Affordable Healthcare Act In Queens
The insurance premiums will vary based on where you live, the number of people included in the plan and your income. The focus of the plan is health maintenance, preventative healthcare and early detection. It is far less expensive to treat a healthcare problem [actually any problem] earlier rather than later. For example putting someone on a cholestorol lowering drug [or better yet getting them to change their diet and increase exercise] is far less expensive than open heart surgery. It's not just lower healthcare costs, it's also enables a far higher quality of life.
Federal government reimbursements are also going to change to incent the right behaviors by healthcare providers. Healthcare providers, such as Mount Sinai Queens Hospital, will be measured based on patient satisfaction and efficiency of their cost structure. These will be included with other metrics in determining payouts.
Insurance Premiums Down In 2012 - Affordable Care Act - Queens
One woman noted that for the first time ever, her insurance premiums went down last year. Congressman Crowley noted that in 2012, the increase in the cost of healthcare was the lowest in 30 years. He said it was because of the preparations for the implementation of the Affordable Healthcare Act.
Caryn Schwab noted that Mount Sinai Queens sees over 50,000 visits annually in the Emergency Department. The Astoria Hospital admits about 18% of those patients. The rest are treated in the ED and released. She observed that many people use the Emergency room as a primary care facility, which is the most expensive route to go in managing your health - because your treating problems that are in the later stages versus treating them in the early stages. It is expected that the Affordable Healthcare Act will change that.
Flexible Spending Accounts In Queens - Obamacare 2013 / 2014
Flexible spending accounts can be used for co-pays and insurance deductibles. Participating in the insurance exchanges / marketplace depends on your income and the tax credits available to you.
Federal Government Program - Subsidies & Economies Of Scale
It was noted that the subsidies would be managed by the federal government, with the states assuming about 10% of the load by 2020. The subsidies will also be funded in part by a 2.3% tax on profits above a $500,000 gain on the sale of homes. This money will go into a fund.
Another means by which it's funded is that by having more people on the plan, it increases negotiating power and enables cost efficiencies / economies of scale. Economies of scale are efficiencies gained when one obtains greater use from an asset. An example of this would be a clinic building or equipment. If the building and equipment cost $1000 and it's only used ten times per year, then the cost per use is $100 [$1000 / 10 uses = $100 per use]. But if the same clinic is used 1000 times, then the cost per use is $1 [$1000 / 1000 uses = $1 per use].
Affordable Healthcare Act In Queens - An EVOLVING Solution
Congressman Crowley reiterated that this is a first real attempt to address the issues associated with spiraling healthcare costs and low healthcare participation rates in America. He noted that they are already aware of unresolved issues such as need to increase fee structure for participating physicians, the need for more primary care physicians in general, and something related to how this impacts union healthcare plans. As in any new program, adjustments will have to be made as the plan is implemented.
Healthcare Navigators In Queens - Obamacare
Rebecca Jackson, Project Coordinator for NYS, told us that there are over 400 Navigators, hired by the State of New York, to help people evaluate and choose the right plans. The service is free and a part of the program. All of these people have been trained and certified. LINK.
You can reach them by calling 1.855.355.5777. Congressman Crowley also provided the telephone number for his office 718.779.1400, should you need printed materials. [Editor's Note: the Queens Library recently upgraded many of its internet connections and offers free access to computers during hours of operations for those who do not have home internet access.].
Caveat - Going Over The Limit & Paying It All Back
One of the caveats of the program is that if you go over the income limits - by even 1 cent, you'll have to pay all of the subsidies back. I'm not completely sure I have this correct and am trying to obtain confirmation, but in the meantime, take heed.
NYS Exchange Enrollments - Who Needs To Enroll & By When
NYS Exchange enrollment began on October 1, 2013 in spite of the Republican-lead effort to stop the program from being implemented, by attempting to shut down the federal government in the Fall of 2013.
If you don't have insurance and don't plan to pay the exemption fees, then NYS residents must register with the exchange by the 15th of the month to be included in the insurance plan by the 1st of the following month. Hence to be insured by January 1, 2014, you need to have enrolled by December 15th, 2013. If you miss that date, you can enroll by January 15th, 2014 to be insured by February 1, 2014. Open enrollment ends on March 31, 2014 for the 2014 tax year. There are life changing exceptions where you can enroll at other times of the year and there are other rules for [I believe both] Medicare / Medicaid clients.
Many Thanks To The United Civic Community Association &
We want to thank the United Civic Community Association and President Rose Marie Poveromo for organizing this important forum at the Museum of the Moving Image in Astoria.
We also wish to thank the panel of experts which included U.S. Congressman Joseph Crowley, Rebecca Jackson, a NY State of Health Project Coordinator, Caryn Schwab Executive Director of Mount Sinai Queens, Judy Trilivas Chief Operating Officer of Mount Sinai Queens and Minna Elias Congresswoman Maloney’s Chief of Staff for their well informed answers.
I left thinking that many of the details of the Affordable Healthcare Act were more clear to me now. Given the magnitude of this change / new program, it is expected that there will be bumps along the way. There was some sense of excitement in the room as several of the attendees voiced their support for the program where it is expected that 44 million more Americans will have access to Affordable Healthcare - which is expected to become preventative healthcare.
Small business owners should call the NYS Navigator number 1.855.355.5777 or Congressman Crowley's office 718.779.1400 [if out of his district he'll forward the call to the appropriate Congressional Representative in Queens] to learn about what sort of tax breaks and subsidies are available for small business based on specific operations. Link to NYS Insurance Exchange.
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