Herald-Tribune Health Reporter Anna Scott answers questions about how the health care legislation will affect Floridians. The questions are hypothetical.
Q: Like many residents in the Sarasota area, I rely on Medicare. How will I be affected? What if I have a special policy? Will it be affected? And what does it mean when they say it will close the doughnut hole in Medicare coverage?
A: Medicare recipients who face the biggest impact are those covered by Medicare Advantage plans, which are privatized Medicare plans that cost more and often give extra benefits such as the "Silver Sneakers" gym memberships and free eyeglasses. Subsidies given by the government to insurers to provide those plans will be cut back substantially. Seniors enrolled in Advantage plans could see a reduction in benefits or an increase in premiums or co-pays, but it is still unclear how insurers will react. On Monday, representatives for Humana, the largest provider of Advantage plans in Florida, said their experts were still reviewing the new legislation and it was too soon to say how it might affect their policies.
The "doughnut hole" refers to the gap in the Medicare prescription drug benefit that seniors experience after they have spent $2,830, when they can no longer get their prescription drugs at a discount. This year, those seniors who reach the limit will get a $250 rebate. Starting in 2011, they will get a 50 percent discount. The gap will be eliminated by 2020, when seniors will be expected to pay 25 percent of the cost of their medications until catastrophic coverage starts.
Government subsidies will be reduced for individuals making more than $85,000 or couples making more than $170,000.
Q: Within 10 years, 95 percent of Americans are expected to have health insurance, under this plan. How will this affect Sarasota and Manatee memorial hospitals and other public facilities which today treat -- and must make up the cost for -- uninsured patients?
A: With more patients insured, the hospitals stand to receive payments for some of the care they currently provide for free. Both hospitals absorb millions each year in bad debts and charity care, more than is covered by tax dollars or local trust funds. But rising numbers of people seeking care could put further pressure on the physician work force, which already faces shortages not addressed by the health care bill.
Q: I have been denied health insurance because of a pre-existing condition -- a bout with breast cancer five years ago, now in remission. Will I be able to get affordable insurance now that will cover me if the cancer reoccurs? What is the high-risk pool the government is talking about?
A: The government will begin operating a temporary high-risk insurance pool in the next six months for people who cannot get insurance because of pre-existing conditions and who have been without insurance for at least six months. Maximum out-of-pocket medical costs for people in the pool will be, annually, $5,950 for individuals and $11,900 for families. The pool will operate until 2014, when insurers will no longer be allowed to drop or deny people with pre-existing conditions.
Q: I am 23 years old. Will I be able to stay on my parents' coverage until I am 26? What if my parents are uninsured or on Medicare? When I turn 27, will I be required to have my own health insurance, just as I must have car insurance?
A: By September, insurers will be forced to let older children through age 26 be covered under their parents' policies. Insurers will also have to cover those adult children even if they have pre-existing health conditions. (Insurers will not have to cover other adults with pre-existing conditions until 2014.)
Starting at age 27, most adults will be required to buy health insurance or pay a fine. If you are under 30, you will be allowed to buy a stripped down plan that covers catastrophic costs and as few as three doctor visits a year. Exempt from the mandate are American Indians and people with religious objections. Also, if you would have to pay more than 8 percent of your income for the cheapest available plan, you will not be penalized for not buying insurance.
The fines will be phased in, starting at 1 percent of income in 2014, and rising to the maximum of $2,085 for a family in 2016.
Q: My wife and I have a combined income of $250,000. I hear our taxes will go up to help pay for this insurance expansion. What will it cost me?
A: Starting in 2013, you will pay a higher Medicare payroll tax of 2.35 percent on earnings of more than $200,000 a year and couples earning more than $250,000. That is an increase from the current 1.45 percent.
You will also see an additional 3.8 percent tax on unearned income such as dividends and interest over the threshold.
Q: I own a restaurant with 10 full-time employees and 20 part-timers. There's no way I can afford to offer health insurance. Will I be forced to now? My sister owns a bigger business with 75 full-timers. How will it affect her? What are my options?
A: Companies with fewer than 50 employees will not have to provide health insurance. If there are 25 or fewer employees and the average salary is $50,000, then companies can get a tax credit of up to 50 percent if they buy insurance for workers.
If a company has more than 50 employees and does not pay for health insurance, and if any of those employees qualify to receive a government subsidy to buy health insurance, that company will be fined. The penalty is $2,000 per full-time employee buying insurance from one of the health exchanges. Two part-time workers count as one full-time worker.
Q: I lost my job two years ago and have exhausted my COBRA coverage. What will this bill do to help me?
A: You may qualify for Medicaid under the bill's expansion of the program. It increases the income limit to up to 133 percent of the federal poverty level, $29,327 a year for a family of four. And starting in 2014, childless adults will be covered for the first time under Medicaid, which in many states such as Florida covers primarily children and women with children.
Q: I am employed but still cannot afford health insurance. What are my new options?
A: If your employer's policy covers less than 60 percent of your health care costs, or if you are paying more than 9.5 percent of your income to get coverage, you can get a subsidy to buy coverage on a health insurance exchange.
Government subsidies of about $2,000 to $4,000 will be given to a family of four earning up to $88,000 and individuals earning up to about $43,000.
The exchange will be a marketplace of various insurance plans that will have to adhere to rules requiring them to cover a range of benefits such as hospitalizations, doctor visits, drugs, maternity care and some preventative tests.
Q: I rely on Medicaid but I'm not happy about it because it is hard to find doctors who will see me. What does this plan mean for me?
A: More doctors are expected to see Medicaid patients under the plan because the reimbursement will increase. Starting in 2014, doctors who see Medicaid patients will be reimbursed by the government at the same level as Medicare.
Q: Will the new health bill provide federal funding for abortions?
A: States can prevent you from getting abortion coverage if you receive one of the subsidies to buy insurance in the health exchange. If the state does not prohibit it, you may have to pay a separate premium to cover the procedure.
SOURCES: Kaiser Family Foundation; The New York Times; The Associated Press.
Herald-Tribune staff writer Dale White contributed to this report.