6
Perspectives JOHN DARKOW Darkow cracks Ted Cruz’s “Green Eggs” exposition. EDITORIAL, 2C OPINIONS Hank Waters likes administrator’s community school idea. Terry Schlemeier knows where rodeo clown can find work. Ron Leone takes issue with push for ethanol increase in fuel. EDITORIAL and OPINION, 2C and 3C Sunday, September 29, 2013 Columbia Daily Tribune SECTION www.columbiatribune.com SPEAK YOUR MIND Comment on any story or column at www. columbiatribune.com. A dose of uncertainty Q&A Supporters believe the law will deliver on its promise to provide affordable insurance and consumer protections for millions of uninsured Americans, and opponents warn of unknown, unintended consequences, including crush- ing costs to taxpayers. The law has been dissected and debated through three national elections, Congress has voted 40 times to repeal it and the U.S. Supreme Court — by a slim 5-4 margin — upheld the bulk of the law last summer. Despite the rancor and contentious debate, Obamacare is the law of the land, and while congressional efforts to repeal or defend the law continue, roughly 75 percent of the law already has been implemented. A rule that allows dependents to stay on a parent’s insur- ance until the age of 26, prohibition against denying cover- age to children for pre-existing conditions, and removing the cap on lifetime coverage limits are just a few of the more than 70 provisions already in place. At least 17 more will be phased in between 2014 and 2018. Tuesday’s scheduled launch of a six-month enrollment period for coverage through Missouri’s federally run health insurance exchange, or marketplace, is one of the biggest hallmarks of the health reform law. Policies purchased through the online marketplace will begin Jan. 1. Failure to purchase insurance could result in a fine, although many health policy analysts have said that most people won’t feel or see any change on Jan. 1 because 80 percent of the nation’s non-elderly population already has insurance. In addition, the Congressional Budget Office estimates that most people who remain uninsured will be young or poor or both and won’t have to pay the penalty. Missouri is a different creature altogether when it comes to Obamacare and its provisions to expand Medicaid and launch the online marketplace. The General Assembly has rejected Medicaid expansion — even with the feds dan- gling the carrot of covering 100 percent of the expansion cost for three years — and the state also refused to put together its own marketplace, forcing the feds to take on that task. Medicaid expansion was seen as the key to helping an estimated 32 million Americans find affordable health cov- erage. The Medicaid debate is expected to be front-and- center once again when the General Assembly convenes in January. Darin Preis, executive director of Central Missouri Com- munity Action and a member of the Columbia Board of Education, said CMCA will have a staff of six consumer assistance counselors, funded by a grant from the Missouri Foundation for Health, to help people enroll in the online marketplace. The counselors will be aiming to enroll peo- ple who fall between 100 percent and 400 percent of the federal poverty level. People with incomes less than 100 percent of the federal poverty level will have to buy insurance on the marketplace because the Medicaid program was not expanded. “They’re falling through a crack that our state legislature chose to put in place,” Preis said. “I’m sincerely hoping they’ll come back in the next legislative session and take a look at that … so the people who most need preventative care can access it.” O bamacare. Few words trigger as much emotion as the nickname for the Patient Pro- tection and Affordable Care Act, which was signed into law by President Barack Obama in March 2010. Critics and propo- nents both use the term — it started as a pejora- tive but was embraced by Obama — yet the law itself continues to divide. BY JODIE JACKSON JR. [email protected] | 815-1713 C heryl Price knows all too well the public’s misperception that indi- viduals with disabilities auto- matically qualify for services or finan- cial assistance. “ ‘There’s programs out there for all you folks, so why don’t you go get it?’ ” she said, repeating the sentiment she often hears. But Price laughs it off, shaking her head and smiling. As the president of the board of directors for Services for Independent Living, Price — who uses a wheelchair — is a tireless advocate for people with disabilities and SIL’s mis- sion of maximizing independence for people with disabilities. She is waiting to see how SIL consum- ers — the organization doesn’t call them “clients” — will fare under the online health insurance marketplace, which is a primary feature of Obamacare. Enroll- ment is set to begin Tuesday. “Are people really going to be able to afford it? Is it truly going to be less expensive?” she asked. Price, 63, is a retired federal employ- ee and has a BlueCross/BlueShield Anthem plan through the government, combined with Medicare for her dis- ability. She is not unhappy with the plan but wouldn’t mind saving money. “I have what Congress has,” she said. “I just have to pay for it. They don’t.” Most of her needs are met. She pays about $200 per month for medications, and most hospitalizations and doctor’s visits are paid for. “It’s going to be a real struggle for me … to decide if I want to give that up” for a health plan on the marketplace, also known as the exchange. “It basically covered everything I needed.” Almost everything. Price longs to have a personal care attendant for tasks that now are done by her husband, who has chronic back problems and diabetes. The attendant would cost at least $20 per hour, and at six hours a day, “that’s more than I make” in a month. If she qualified for Medicaid — or if the Missouri General Assembly agreed to expand Medicaid, with the feds cov- ering 100 percent of the expansion cost for three years — Price could get the attendant she needs. Instead, her monthly retirement and disability income is $17 more than the threshold to receive Medicaid. “Seventeen bucks makes all that dif- ference in your life,” she said. “Our state legislature really needs to buy into Medicaid expansion.” Price’s “new birthday” — the term some individuals with disabilities use for the date of injury or disability — was June 19, 1980. She fell and suffered a traumatic brain injury while she was between shifts as a nurse at Truman Memorial Veterans’ Hospital. She broke all the bones in her face. A medical condition related to her brain injury was treated with high doses of steroids, which caused osteoporosis, eventually requiring Price to begin using a wheelchair in 1998. Price also is eager to see how the marketplace and new insurance regula- tions might help her husband gain insurance. He could buy insurance now for around $1,200 per month, but that will likely change. “Before Obamacare, most of the Medi- care supplement policies wouldn’t accept him because of pre-existing conditions,” she said. That discrimination is outlawed effective Jan. 1. At that point, people can be charged more but can’t be denied coverage if they have a pre-existing men- tal, physical or medical condition. Advocate for disabled hopes for improvement Don Shrubshell/Tribune THE FACES OF HEALTHCARE | WHO WILL BE AFFECTED? Although 75 percent of Obamacare has already been implemented, sweeping changes ahead pose a myriad of unanswered questions. Nick Schnelle/Tribune Jen Bersdale, executive director of Missouri Health Care for All, speaks Tuesday during a panel lecture aimed at providing tips and tools to communicate about the new health care exchanges during the 2013 Cover Missouri Summit at the Holiday Inn Executive Center. Q: I am 78 years old, and my Q: I am 78 years old, and my husband is 80. Do we have to husband is 80. Do we have to sign up for the new Obama- sign up for the new Obama- care since we have paid into care since we have paid into Medicare for years? … We do Medicare for years? … We do not understand this law and not understand this law and do not understand what we do not understand what we have to do to sign in. This have to do to sign in. This is confusing. Thank you for is confusing. Thank you for answering my question. Sin- answering my question. Sin- cerely, M.L., Glasgow cerely, M.L., Glasgow A: Your Medicare benefits A: Your Medicare benefits are not changing under the are not changing under the Affordable Care Act (Obama- Affordable Care Act (Obama- care). care). If you get your health If you get your health care through a government care through a government plan such as Medicare or plan such as Medicare or Medicaid, you do not need to Medicaid, you do not need to enroll for insurance through enroll for insurance through the online marketplace that the online marketplace that launches Tuesday. launches Tuesday. “We want to reassure Medi- “We want to reassure Medi- care beneficiaries that they are care beneficiaries that they are already covered, their benefits already covered, their benefits aren’t changing and the mar- aren’t changing and the mar- ketplace doesn’t require them ketplace doesn’t require them to do anything different,” said to do anything different,” said Julie Bataille, spokeswoman Julie Bataille, spokeswoman for the Centers for Medicare for the Centers for Medicare and Medicaid Services. and Medicaid Services. She said call centers for the She said call centers for the state exchanges are already state exchanges are already fielding questions from Medi- fielding questions from Medi- care recipients and rerouting care recipients and rerouting them to the Medicare line. them to the Medicare line. Another reason for the Another reason for the confusion is the overlapping confusion is the overlapping enrollment periods for Medi- enrollment periods for Medi- care and Obamacare. Medicare care and Obamacare. Medicare open enrollment starts Oct. open enrollment starts Oct. 15 and closes Dec. 7, while 15 and closes Dec. 7, while enrollment for the new state enrollment for the new state exchanges for people 65 and exchanges for people 65 and younger launches Tuesday and younger launches Tuesday and runs through March. Many of runs through March. Many of the same insurance companies the same insurance companies offer coverage for both. offer coverage for both. Be aware of possible Medi- Be aware of possible Medi- care-related scams that are care-related scams that are adding to the confusion. Joyce adding to the confusion. Joyce Jones of Columbia said she Jones of Columbia said she received a phone call from a received a phone call from a person who told her she was person who told her she was going to get a new Medicare going to get a new Medicare card in the mail. The man card in the mail. The man then asked her to confirm her then asked her to confirm her phone number and address. phone number and address. “He said he was going to “He said he was going to have to ask me more personal have to ask me more personal questions to verify I was who questions to verify I was who I said I am,” Jones reported. “I I said I am,” Jones reported. “I knew right then and there it knew right then and there it was a scam.” was a scam.” She knows Medicare officials She knows Medicare officials do not ask for information over do not ask for information over the phone. At that point, the the phone. At that point, the caller hung up. caller hung up. Jones reported the phone Jones reported the phone call to the Missouri Attorney call to the Missouri Attorney General’s Office and to the De- General’s Office and to the De- partment of Health and Human partment of Health and Human Services Office of Inspector Services Office of Inspector General, which confirmed the General, which confirmed the call did not come from HHS or call did not come from HHS or the Centers for Medicare and the Centers for Medicare and Medicaid Services. Medicaid Services. “They were the ones who “They were the ones who told me they were well-aware told me they were well-aware of this scam,” she said. of this scam,” she said. CHERYL PRICE AGE: 63 63 OCCUPATION: Retired Retired CURRENT MEDICAL SITUATION: Disabled Disabled INCOME: Price makes $17 too Price makes $17 too much each month to qualify for much each month to qualify for Medicaid Medicaid By Jodie Jackson Jr. | [email protected] | 815-1713 CONTINUED ON 4C DIAGNOSIS: CONFUSION A HEALTH CARE SYSTEM IN TRANSITION COMING TUESDAY: Who are the navigators and enrollment assistants who are helping people enroll in the health insurance marketplace? COMING WEDNESDAY: How do the health insurance marketplaces work, and how much does insurance cost? A MULTIPART SERIES ON HOW THE LOOMING HEALTH CARE REFORMS WILL CHANGE THE LIVES OF MID-MISSOURIANS.

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Page 1: Diagnosis Confusion

Perspectives

JOHN DARKOWDarkow cracks Ted Cruz’s “Green Eggs” exposition.

EDITORIAL, 2C

OPINIONSHank Waters likes administrator’s community school idea. Terry Schlemeier knows where rodeo clown can find work. Ron Leone takes issue with push for ethanol increase in fuel.

EDITORIAL and OPINION, 2C and 3C

Sunday, September 29, 2013

Columbia Daily TribuneSECTION

www.columbiatribune.com

SPEAK YOUR MINDComment on any story or column at www.columbiatribune.com.

A dose of uncertainty

Q&A

Supporters believe the law will deliver on its promise to provide affordable insurance and consumer protections for millions of uninsured Americans, and opponents warn of unknown, unintended consequences, including crush-ing costs to taxpayers.

The law has been dissected and debated through three national elections, Congress has voted 40 times to repeal it and the U.S. Supreme Court — by a slim 5-4 margin — upheld the bulk of the law last summer.

Despite the rancor and contentious debate, Obamacare is the law of the land, and while congressional efforts to repeal or defend the law continue, roughly 75 percent of the law already has been implemented.

A rule that allows dependents to stay on a parent’s insur-ance until the age of 26, prohibition against denying cover-age to children for pre-existing conditions, and removing the cap on lifetime coverage limits are just a few of the more than 70 provisions already in place. At least 17 more will be phased in between 2014 and 2018.

■Tuesday’s scheduled launch of a six-month enrollment

period for coverage through Missouri’s federally run health insurance exchange, or marketplace, is one of the biggest hallmarks of the health reform law. Policies purchased through the online marketplace will begin Jan. 1.

Failure to purchase insurance could result in a fine, although many health policy analysts have said that most people won’t feel or see any change on Jan. 1 because 80 percent of the nation’s non-elderly population already has insurance. In addition, the Congressional Budget Office estimates that most people who remain uninsured will be young or poor or both and won’t have to pay the penalty.

Missouri is a different creature altogether when it comes to Obamacare and its provisions to expand Medicaid and launch the online marketplace. The General Assembly has rejected Medicaid expansion — even with the feds dan-gling the carrot of covering 100 percent of the expansion cost for three years — and the state also refused to put

together its own marketplace, forcing the feds to take on that task.

Medicaid expansion was seen as the key to helping an estimated 32 million Americans find affordable health cov-erage. The Medicaid debate is expected to be front-and-center once again when the General Assembly convenes in January.

Darin Preis, executive director of Central Missouri Com-munity Action and a member of the Columbia Board of Education, said CMCA will have a staff of six consumer assistance counselors, funded by a grant from the Missouri Foundation for Health, to help people enroll in the online marketplace. The counselors will be aiming to enroll peo-ple who fall between 100 percent and 400 percent of the federal poverty level.

People with incomes less than 100 percent of the federal poverty level will have to buy insurance on the marketplace because the Medicaid program was not expanded.

“They’re falling through a crack that our state legislature chose to put in place,” Preis said. “I’m sincerely hoping they’ll come back in the next legislative session and take a look at that … so the people who most need preventative care can access it.”

Obamacare.

Few words trigger as much emotion as the nickname for the Patient Pro-tection and Affordable Care Act, which was signed into law by President

Barack Obama in March 2010. Critics and propo-nents both use the term — it started as a pejora-tive but was embraced by Obama — yet the law itself continues to divide.

BY JODIE JACKSON [email protected] | 815-1713

Cheryl Price knows all too well the public’s misperception that indi-viduals with disabilities auto-

matically qualify for services or finan-cial assistance.

“ ‘There’s programs out there for all you folks, so why don’t you go get it?’ ” she said, repeating the sentiment she often hears.

But Price laughs it off, shaking her head and smiling. As the president of the board of directors for Services for Independent Living, Price — who uses a wheelchair — is a tireless advocate for people with disabilities and SIL’s mis-sion of maximizing independence for people with disabilities.

She is waiting to see how SIL consum-ers — the organization doesn’t call them “clients” — will fare under the online health insurance marketplace, which is a primary feature of Obamacare. Enroll-ment is set to begin Tuesday.

“Are people really going to be able to

afford it? Is it truly going to be less expensive?” she asked.

Price, 63, is a retired federal employ-ee and has a BlueCross/BlueShield Anthem plan through the government, combined with Medicare for her dis-ability. She is not unhappy with the plan but wouldn’t mind saving money.

“I have what Congress has,” she said. “I just have to pay for it. They don’t.”

Most of her needs are met. She pays about $200 per month for medications, and most hospitalizations and doctor’s visits are paid for.

“It’s going to be a real struggle for me … to decide if I want to give that up” for a health plan on the marketplace, also known as the exchange. “It basically covered everything I needed.”

Almost everything.Price longs to have a personal care

attendant for tasks that now are done by her husband, who has chronic back problems and diabetes. The attendant would cost at least $20 per hour, and at six hours a day, “that’s more than I

make” in a month.If she qualified for Medicaid — or if

the Missouri General Assembly agreed to expand Medicaid, with the feds cov-ering 100 percent of the expansion cost for three years — Price could get the attendant she needs. Instead, her monthly retirement and disability income is $17 more than the threshold to receive Medicaid.

“Seventeen bucks makes all that dif-ference in your life,” she said. “Our state legislature really needs to buy into Medicaid expansion.”

Price’s “new birthday” — the term

some individuals with disabilities use for the date of injury or disability — was June 19, 1980. She fell and suffered a traumatic brain injury while she was between shifts as a nurse at Truman Memorial Veterans’ Hospital.

She broke all the bones in her face. A medical condition related to her brain injury was treated with high doses of steroids, which caused osteoporosis, eventually requiring Price to begin using a wheelchair in 1998.

Price also is eager to see how the marketplace and new insurance regula-tions might help her husband gain insurance. He could buy insurance now for around $1,200 per month, but that will likely change.

“Before Obamacare, most of the Medi-care supplement policies wouldn’t accept him because of pre-existing conditions,” she said. That discrimination is outlawed effective Jan. 1. At that point, people can be charged more but can’t be denied coverage if they have a pre-existing men-tal, physical or medical condition.

Advocate for disabled hopes for improvement

Don Shrubshell/Tribune

THE FACES OF HEALTHCARE | WHO WILL BE AFFECTED?

Although 75 percent of Obamacare has already been implemented, sweeping changes ahead pose a myriad of unanswered questions.

Nick Schnelle/TribuneJen Bersdale, executive director of Missouri Health Care for All, speaks Tuesday during a panel lecture aimed at providing tips and tools to communicate about the new health care exchanges during the 2013 Cover Missouri Summit at the Holiday Inn Executive Center.

Q: I am 78 years old, and my Q: I am 78 years old, and my husband is 80. Do we have to husband is 80. Do we have to sign up for the new Obama-sign up for the new Obama-care since we have paid into care since we have paid into Medicare for years? … We do Medicare for years? … We do not understand this law and not understand this law and do not understand what we do not understand what we have to do to sign in. This have to do to sign in. This is confusing. Thank you for is confusing. Thank you for answering my question. Sin-answering my question. Sin-cerely, M.L., Glasgowcerely, M.L., GlasgowA: Your Medicare benefi ts A: Your Medicare benefi ts are not changing under the are not changing under the Aff ordable Care Act (Obama-Aff ordable Care Act (Obama-care).care). If you get your health If you get your health care through a government care through a government plan such as Medicare or plan such as Medicare or Medicaid, you do not need to Medicaid, you do not need to enroll for insurance through enroll for insurance through the online marketplace that the online marketplace that launches Tuesday.launches Tuesday.

“We want to reassure Medi-“We want to reassure Medi-care benefi ciaries that they are care benefi ciaries that they are already covered, their benefi ts already covered, their benefi ts aren’t changing and the mar-aren’t changing and the mar-ketplace doesn’t require them ketplace doesn’t require them to do anything diff erent,” said to do anything diff erent,” said Julie Bataille, spokeswoman Julie Bataille, spokeswoman for the Centers for Medicare for the Centers for Medicare and Medicaid Services.and Medicaid Services.

She said call centers for the She said call centers for the state exchanges are already state exchanges are already fi elding questions from Medi-fi elding questions from Medi-care recipients and rerouting care recipients and rerouting them to the Medicare line.them to the Medicare line.

Another reason for the Another reason for the confusion is the overlapping confusion is the overlapping enrollment periods for Medi-enrollment periods for Medi-care and Obamacare. Medicare care and Obamacare. Medicare open enrollment starts Oct. open enrollment starts Oct. 15 and closes Dec. 7, while 15 and closes Dec. 7, while enrollment for the new state enrollment for the new state exchanges for people 65 and exchanges for people 65 and younger launches Tuesday and younger launches Tuesday and runs through March. Many of runs through March. Many of the same insurance companies the same insurance companies off er coverage for both.off er coverage for both.

Be aware of possible Medi-Be aware of possible Medi-care-related scams that are care-related scams that are adding to the confusion. Joyce adding to the confusion. Joyce Jones of Columbia said she Jones of Columbia said she received a phone call from a received a phone call from a person who told her she was person who told her she was going to get a new Medicare going to get a new Medicare card in the mail. The man card in the mail. The man then asked her to confi rm her then asked her to confi rm her phone number and address.phone number and address.

“He said he was going to “He said he was going to have to ask me more personal have to ask me more personal questions to verify I was who questions to verify I was who I said I am,” Jones reported. “I I said I am,” Jones reported. “I knew right then and there it knew right then and there it was a scam.”was a scam.”

She knows Medicare offi cials She knows Medicare offi cials do not ask for information over do not ask for information over the phone. At that point, the the phone. At that point, the caller hung up.caller hung up.

Jones reported the phone Jones reported the phone call to the Missouri Attorney call to the Missouri Attorney General’s Offi ce and to the De-General’s Offi ce and to the De-partment of Health and Human partment of Health and Human Services Offi ce of Inspector Services Offi ce of Inspector General, which confi rmed the General, which confi rmed the call did not come from HHS or call did not come from HHS or the Centers for Medicare and the Centers for Medicare and Medicaid Services.Medicaid Services.

“They were the ones who “They were the ones who told me they were well-aware told me they were well-aware of this scam,” she said.of this scam,” she said.

CHERYL PRICEAGE: 6363OCCUPATION: RetiredRetiredCURRENT MEDICAL SITUATION: Disabled Disabled INCOME: Price makes $17 too Price makes $17 too much each month to qualify for much each month to qualify for MedicaidMedicaid

By Jodie Jackson Jr. | [email protected] | 815-1713

CONTINUED ON 4C

DIAGNOSIS: CONFUSIONA HEALTH CARE SYSTEM IN TRANSITION

COMING TUESDAY: Who are the navigators and enrollment assistants who are helping people enroll in the health insurance marketplace?

COMING WEDNESDAY: How do the health insurance marketplaces work, and how much does insurance cost?

A MULTIPART SERIES ON HOW THE LOOMING HEALTH CARE REFORMS WILL CHANGE THE LIVES OF MID-MISSOURIANS.

Page 2: Diagnosis Confusion

4C www.columbiatribune.com COLUMBIA DAILY TRIBUNE Sunday, September 29, 2013

DIAGNOSIS: CONFUSIONA HEALTH CARE SYSTEM IN TRANSITION

President Barack Obama on March 23, 2010, signed into law the Patient Protection and Afford-able Care Act. The U.S. Supreme Court, in a 5-4

decision, upheld most aspects of the law in a ruling on June 28, 2012. To date, at least 71 major provisions of the law have been implemented, with 17 more to come from 2014-20. Here are some highlights:

2010-2012�Provides a tax credit for small businesses for Provides a tax credit for small businesses for as much as 35 percent of their contribution to as much as 35 percent of their contribution to purchasing health insurance for their employ-purchasing health insurance for their employ-ees. Estimated at $40 billion over 10 years.ees. Estimated at $40 billion over 10 years.�Provides for increased federal taxpayer fund-Provides for increased federal taxpayer fund-ing for community health centers totaling $11 ing for community health centers totaling $11 billion over fi ve years.billion over fi ve years.�Obamacare closes the Part D Medicare Obamacare closes the Part D Medicare Coverage Gap, or “doughnut hole,” that forced Coverage Gap, or “doughnut hole,” that forced seniors to pay out of pocket for drug costs. It seniors to pay out of pocket for drug costs. It also includes a 50 percent discount on brand-also includes a 50 percent discount on brand-name drugs. Seniors now get a rebate to cover name drugs. Seniors now get a rebate to cover the costs, and Obamacare closes the Medicare the costs, and Obamacare closes the Medicare coverage gap for good in 2020.coverage gap for good in 2020.�Health insurance companies can’t drop your Health insurance companies can’t drop your coverage when you are sick.coverage when you are sick.�Children younger than 19 can’t be classifi ed Children younger than 19 can’t be classifi ed as having pre-existing conditions.as having pre-existing conditions.�Children younger than 26 can stay on their Children younger than 26 can stay on their parents’ insurance.parents’ insurance.�Creates a high-risk pool for individuals with Creates a high-risk pool for individuals with pre-existing conditions. These individuals can pre-existing conditions. These individuals can still get treatment but at higher rates. The high-still get treatment but at higher rates. The high-risk pool disappears in 2017, at which point risk pool disappears in 2017, at which point high-risk individuals will buy the same insur-high-risk individuals will buy the same insur-ance as everyone else.ance as everyone else.�Rate hike review is implemented. Insurers no Rate hike review is implemented. Insurers no longer can increase your premiums to increase longer can increase your premiums to increase profi ts. They must justify rate hikes of more profi ts. They must justify rate hikes of more

than 10 percent to the state and then display than 10 percent to the state and then display them on their website and a government web-them on their website and a government web-site the same day.site the same day.�The 80/20 rule is implemented. Insurance The 80/20 rule is implemented. Insurance companies now have to tell their customers companies now have to tell their customers how their money is being spent. If insurers how their money is being spent. If insurers don’t spend at least 80 percent of the premi-don’t spend at least 80 percent of the premi-ums on health care, they have to give custom-ums on health care, they have to give custom-ers a rebate for the diff erence. To date, Ameri-ers a rebate for the diff erence. To date, Ameri-cans have received $1.1 billion in rebates. cans have received $1.1 billion in rebates. �Increased reimbursement to physicians, Increased reimbursement to physicians, mostly in rural areas.mostly in rural areas.�Employers must list employee benefi ts on Employers must list employee benefi ts on their tax forms. This helps to determine wheth-their tax forms. This helps to determine wheth-er the company will get tax breaks or credits er the company will get tax breaks or credits for insuring employees.for insuring employees.�All new plans must provide free preventive All new plans must provide free preventive care.care.�Obamacare establishes state consumer Obamacare establishes state consumer assistance programs to help consumers fi le assistance programs to help consumers fi le complaints and appeals, and enroll in health complaints and appeals, and enroll in health care and other consumer-related assistance care and other consumer-related assistance to better understand trouble spots that need to better understand trouble spots that need oversight.oversight.�The hospital “pay-for-quality” program be-The hospital “pay-for-quality” program be-gins. This is part of an overall eff ort to promote gins. This is part of an overall eff ort to promote quality not quantity in the health care industry. quality not quantity in the health care industry. A portion of Medicare payments is withheld A portion of Medicare payments is withheld from hospitals that don’t meet readmission from hospitals that don’t meet readmission criteria.criteria.�There is a 3.8 percent tax increase on capital There is a 3.8 percent tax increase on capital gains, unearned income, interest, dividends, an-gains, unearned income, interest, dividends, an-nuities, rent, royalties and inactive businesses. nuities, rent, royalties and inactive businesses.

2013�Health Insurance Exchanges open. Those Health Insurance Exchanges open. Those making more than 400 percent of the federal making more than 400 percent of the federal poverty level can shop on the exchange but will poverty level can shop on the exchange but will

not receive tax credits or discounts. The insur-not receive tax credits or discounts. The insur-ance purchased on the exchange doesn’t go ance purchased on the exchange doesn’t go into eff ect until Jan. 1, 2014.into eff ect until Jan. 1, 2014.�Tax credits, discounts on out-of-pocket costs, Tax credits, discounts on out-of-pocket costs, tax breaks and other subsides are available on tax breaks and other subsides are available on the exchange. The assistance is directly related the exchange. The assistance is directly related to gross adjusted income.to gross adjusted income.�There is a 0.9 percent Obamacare Medicare There is a 0.9 percent Obamacare Medicare tax on those making more than $200,000 as tax on those making more than $200,000 as an individual or $250,000 as a business or fam-an individual or $250,000 as a business or fam-ily. This applies to between 1.5 to 4.2 percent of ily. This applies to between 1.5 to 4.2 percent of taxpayers.taxpayers.�New rules about the amount that can be New rules about the amount that can be contributed to a Flexible Spending Account. A contributed to a Flexible Spending Account. A cap of $2,500 is applied to reform FSAs and cap of $2,500 is applied to reform FSAs and prevent individuals from overpaying and then prevent individuals from overpaying and then needing to rush to use the money.needing to rush to use the money.�Part D coverage gap, or “doughnut hole” Part D coverage gap, or “doughnut hole” reduction, goes into eff ect.reduction, goes into eff ect.�Increases from 7.5 to 10 percent the threshold Increases from 7.5 to 10 percent the threshold at which medical expenses, as a percentage of at which medical expenses, as a percentage of income, can be deductible from federal taxes.income, can be deductible from federal taxes.

2014�Individuals can’t be denied coverage for pre-Individuals can’t be denied coverage for pre-existing conditions.existing conditions.�For those who do not purchase health insur-For those who do not purchase health insur-ance, there is a tax starting at 1 percent of your ance, there is a tax starting at 1 percent of your income to a maximum $95 and increasing to income to a maximum $95 and increasing to 2.5 percent of your income or a maximum of 2.5 percent of your income or a maximum of $685 by 2016 for individuals. For a family, it’s $685 by 2016 for individuals. For a family, it’s capped at $285 in 2014 and rises to $2,085 by capped at $285 in 2014 and rises to $2,085 by 2016. It cannot exceed these amounts. 2016. It cannot exceed these amounts. �Congress must shop on the health insurance Congress must shop on the health insurance exchanges.exchanges.�Many states expand their Medicaid programs Many states expand their Medicaid programs to insure more low-income individuals, with to insure more low-income individuals, with the feds paying 100 percent of the expansion the feds paying 100 percent of the expansion

cost for three years, then 90 percent of the cost for three years, then 90 percent of the additional cost after that. Missouri is among the additional cost after that. Missouri is among the states that opted out of Medicaid expansion.states that opted out of Medicaid expansion.�Employers will be able to shop on the health Employers will be able to shop on the health insurance exchanges for employee insurance.insurance exchanges for employee insurance.

2015�Doctors’ income is based on quality of care, Doctors’ income is based on quality of care, not quantity of care. This provision, also known not quantity of care. This provision, also known as “pay for performance,” replaces the current as “pay for performance,” replaces the current “fee-for-service” payment model.“fee-for-service” payment model.

2017�States have the fl exibility to allow businesses States have the fl exibility to allow businesses with more than 100 employees to purchase with more than 100 employees to purchase coverage in the SHOP (Small Business Health coverage in the SHOP (Small Business Health Options Program) exchange.Options Program) exchange.�No more exceptions for pre-existing condi-No more exceptions for pre-existing condi-tions for anyone, including high-risk customers.tions for anyone, including high-risk customers.

2018�All health care plans — including plans held All health care plans — including plans held since before preventive care was required — since before preventive care was required — must now off er preventive coverage.must now off er preventive coverage.�The “Cadillac” tax for higher-quality coverage The “Cadillac” tax for higher-quality coverage for individuals and employers purchasing insur-for individuals and employers purchasing insur-ance for employees is put in place.ance for employees is put in place.

2020�Obamacare fully eliminates the Medicare Gap Obamacare fully eliminates the Medicare Gap instead of just off ering rebates to seniors.instead of just off ering rebates to seniors.Sources: Obamacarefacts.com; Kaiser Family Sources: Obamacarefacts.com; Kaiser Family Foundation; Center for Health Policy Studies - Foundation; Center for Health Policy Studies - Heritage Foundation Young Leaders Program; Heritage Foundation Young Leaders Program; and the Department of Health and Human and the Department of Health and Human ServicesServices

FYIWHAT DOES THAT WORD MEAN?Obamacare has many terms — some old, some new — that are worth becoming familiar with.Employer mandate: A federal requirement that A federal requirement that companies with 50 or more workers pay a penalty to companies with 50 or more workers pay a penalty to the government if one of its workers obtains taxpay-the government if one of its workers obtains taxpay-er-subsidized coverage through the law. Delayed one er-subsidized coverage through the law. Delayed one year to Jan. 1, 2015. Intended to keep companies from year to Jan. 1, 2015. Intended to keep companies from “dumping” employees into public coverage.“dumping” employees into public coverage.Employer-sponsored insurance: Insurance coverage Insurance coverage purchased through the employer. purchased through the employer. Enrollment period: The dates when consumers or The dates when consumers or their dependents are allowed to enroll in an insurance their dependents are allowed to enroll in an insurance plan. For the initial enrollment in Obamacare, the plan. For the initial enrollment in Obamacare, the period starts Tuesday and ends March 31.period starts Tuesday and ends March 31.Federal poverty level: A measure of income level A measure of income level issued annually by the U.S. Department of Health and issued annually by the U.S. Department of Health and Human Services. Federal poverty levels are used to Human Services. Federal poverty levels are used to determine eligibility for certain programs and ben-determine eligibility for certain programs and ben-efi ts.efi ts.Formulary: A list of drugs that a health plan will cov- A list of drugs that a health plan will cov-er, either fully or in part. Formularies vary by health er, either fully or in part. Formularies vary by health plan. Also called a preferred drug list (PDL).plan. Also called a preferred drug list (PDL).Individual mandate: A requirement that individuals A requirement that individuals buy health insurance or face fi nes. There are exemp-buy health insurance or face fi nes. There are exemp-tions for fi nancial hardship and religious objections.tions for fi nancial hardship and religious objections.Marketplaces:Marketplaces: Online health insurance markets in Online health insurance markets in each state where consumers can get private health each state where consumers can get private health insurance, subsidized by the government. They used insurance, subsidized by the government. They used to be called “exchanges,” but the feds decided that to be called “exchanges,” but the feds decided that was too confusing and started calling them “mar-was too confusing and started calling them “mar-ketplaces.” Marketplaces can be accessed online ketplaces.” Marketplaces can be accessed online through healthcare.gov. Small businesses will have through healthcare.gov. Small businesses will have their own marketplaces.their own marketplaces.Medical Loss Ratio (MLR): A requirement that helps A requirement that helps make sure your monthly payments (premiums) go make sure your monthly payments (premiums) go further in covering your health care. Health plans sold further in covering your health care. Health plans sold to individuals and small business employers must to individuals and small business employers must spend at least 80 cents of each premium dollar on spend at least 80 cents of each premium dollar on health care and as much as 20 cents on administra-health care and as much as 20 cents on administra-tive costs. Plans sold to large employers — generally tive costs. Plans sold to large employers — generally more than 50 employees — must spend at least 85 more than 50 employees — must spend at least 85 cents of every premium dollar on health care and just cents of every premium dollar on health care and just 15 cents on administrative costs.15 cents on administrative costs.Metal levels: The four levels of coverage avail- The four levels of coverage avail-able through exchange plans, called bronze, silver, able through exchange plans, called bronze, silver, gold and platinum. Bronze plans feature the lowest gold and platinum. Bronze plans feature the lowest monthly premiums but cover only 60 percent of monthly premiums but cover only 60 percent of average costs. Platinum plans have higher premiums average costs. Platinum plans have higher premiums and cover 90 percent of expected costs.and cover 90 percent of expected costs.Navigators: People who will help you understand the People who will help you understand the new health coverage options, give you information new health coverage options, give you information on how to enroll and help you select a plan. on how to enroll and help you select a plan. Pre-existing condition: An ongoing or past health An ongoing or past health problem. Insurers now can use pre-existing condi-problem. Insurers now can use pre-existing condi-tions to deny or restrict coverage or charge more. tions to deny or restrict coverage or charge more. Those practices will be barred by federal law starting Those practices will be barred by federal law starting Jan. 1, and insurers will have to accept all applicants.Jan. 1, and insurers will have to accept all applicants.Premium tax credits: An amount that can be sub- An amount that can be sub-tracted from the amount of income tax a person or tracted from the amount of income tax a person or business owes. Premium tax credits will be off ered to business owes. Premium tax credits will be off ered to some individuals and small businesses that purchase some individuals and small businesses that purchase health coverage through Health Insurance Market-health coverage through Health Insurance Market-places to help pay for the cost of coverage. You can places to help pay for the cost of coverage. You can have the tax credit applied to your premium over the have the tax credit applied to your premium over the course of the year or wait until you fi le your taxes to course of the year or wait until you fi le your taxes to claim the full amount.claim the full amount.SHOP: Small Business Health Options Program, a Small Business Health Options Program, a new program designed to simplify the process of new program designed to simplify the process of fi nding a health plan for a small business, generally fi nding a health plan for a small business, generally those with 50 or fewer employees. SHOPs are com-those with 50 or fewer employees. SHOPs are com-petitive marketplaces where small employers can go petitive marketplaces where small employers can go to fi nd health coverage from a selection of providers. to fi nd health coverage from a selection of providers. The small business tax credit is available only through The small business tax credit is available only through a SHOP.a SHOP.Tax credits: Government health insurance subsidies Government health insurance subsidies for individuals will come in the form of tax credits. for individuals will come in the form of tax credits. The money will be paid directly to the consumer’s The money will be paid directly to the consumer’s health plan to help cover premiums. The subsidies health plan to help cover premiums. The subsidies are on a sliding scale based on income. Each year, are on a sliding scale based on income. Each year, people will have to “true up” with the Internal Rev-people will have to “true up” with the Internal Rev-enue Service to make sure they got the right amount. enue Service to make sure they got the right amount. People who receive too generous a tax credit might People who receive too generous a tax credit might owe money back to the government.owe money back to the government.Tax penalty: The fi ne levied on individuals who disre-The fi ne levied on individuals who disre-gard the individual insurance mandate. It starts small gard the individual insurance mandate. It starts small and gets bigger in subsequent years. In 2014, it’s $95 and gets bigger in subsequent years. In 2014, it’s $95 or 1 percent of taxable income. By 2016, it’s $695 or or 1 percent of taxable income. By 2016, it’s $695 or 2.5 percent of taxable income, whichever is greater. 2.5 percent of taxable income, whichever is greater. Thereafter, it’s adjusted for infl ation.Thereafter, it’s adjusted for infl ation.Sources: Department of Health and Human Services, Sources: Department of Health and Human Services, Blue Cross Blue Shield, The Associated Press, Kaiser Blue Cross Blue Shield, The Associated Press, Kaiser Family Foundation, younginvincibles.orgFamily Foundation, younginvincibles.org

A CLOSER LOOK | THE AFORDABLE CARE ACT TIMELINE

Medicaid expansion has been a regular topic of conversation at numerous Obamacare-related conferences and seminars over the past few months. Amy Whitcomb Slemmer, the director of Health Care For All in Massachusetts, recently called for Medicaid expansion during an event in Columbia.

“I understand you don’t have a wildly support-ive legislature,” Slemmer said, telling representa-tives of not-for-profit and social service agencies that they will have important voices in modifying the state’s federally run exchange “as you go.”

“I know there are still people trying to defeat this law, but it is the law of the land,” she said.

The Family Health Center of Boone County also has hired staff to help people enroll, and two Columbia-based statewide groups — Primaris Healthcare Business Solutions and the Missouri Association of Area Agencies on Aging — received sizeable federal grants to hire navigators to help educate and enroll people in the marketplace.

■Insurance plans on the marketplace will range

in price at bronze, silver, gold and platinum levels. Bronze will have the cheapest premiums and highest out-of-pocket costs. On the other end, platinum has the highest premiums but the lowest out-of-pocket costs.

Despite the cost differences, insurance compa-nies no longer can set higher premiums for women, and each plan must provide a list of 10 basic benefits, including maternity care, prescrip-tion drug coverage and mental health care.

In addition, many of those who shop on the online marketplace will be eligible for a subsidy or tax credit based on their income and family size.

Meanwhile, even with the marketplace enroll-ment just days away, confusion about the law continues to abound.

“There are so many unknowns as far as what it’s going to entail and cost, and what benefit you get from it,” said Mike Kinkead, owner of Kinkead Pharmacy/RadioShack in Centralia. “Everybody, including me, is trying to play catch-up as far as finding out all the ins and outs.”

People with Medicare coverage are wondering how the marketplace might affect them. It won’t. Business owners are anxious to learn the specifics of mandates for them to provide coverage to employees. Health care professionals worry that simply providing affordable insurance won’t have a real impact for people who’ve never had insur-ance and who typically wait for a health emer-gency to see a doctor or go to the emergency room.

Kinkead said he’s not well-versed enough to answer peoples’ questions, but he’s not hearing many.

“At this point, we’re not really getting many questions” from pharmacy customers, he said. “The few people I’ve talked to” who had concerns “don’t even know which questions to ask.”

Tom Kayser, benefits division manager at Sund-vold Financial in Columbia, said his job for 25 years has been helping individuals and businesses develop plans and benefits, to negotiate prices, maintain compliance with insurance and finan-cial regulations, and provide ongoing claim sup-port.

That approach is now preceded by “a 1½- to 2-hour conversation just getting them up to speed” on Obamacare “before we can even strat-egize,” Kayser said.

He added, “Unfortunately, this law is making me spend probably 70 percent of the time to make sure that people aren’t in a position to pay exorbi-tant penalties and fines.”

■Even in the midst of the confusion, however,

it’s clear that additional taxes and fees are going to be part of the new health care landscape. The new taxes include a medical device tax, health insurance industry tax and changing the thresh-old on itemized health and medical deductions from 7.5 percent to 10 percent of adjusted gross income.

“The sad thing is so many employers don’t know what’s about to hit them,” Kayser said.

“Small employers are going to have an extreme surprise when it comes to their 2014 renewal.”

One of the potential surprises for employers will be the transitional reinsurance program, also known as the “belly button tax.” The tax, assessed on each covered individual in a health plan, will last for three years and is intended to stabilize the insurance market in case sicker and previously uninsured people flood insurance risk pools with-out a corresponding influx of young, healthy peo-ple.

The belly button tax is estimated to cost Boone County, Columbia city government and the Uni-versity of Missouri system a combined $2.59 mil-lion in 2014.

The coming public blitz of Obamacare and marketplace education also will target young Americans. The need for younger, healthier people to join the marketplace risk pool is “crucial to making this work,” said Ryan Barker, vice presi-dent of health policy for the Missouri Foundation for Health.

“You can’t understate the importance of lots and lots of young, healthy people signing up,” he said.

Twenty-six percent of people ages 18 to 34 are uninsured — the largest population of uninsured Missourians, Barker said.

Kayser is skeptical about the prospect of young people signing up to receive a monthly health insurance bill. Not buying insurance, however, will mean a penalty of $95 or 1 percent of income, although the amount grows substantially larger over the next few years.

At least for now, “the likelihood is those people will remain uninsured because the penalty, the tax, is virtually nonexistent,” Kayser said.

“You’ve got a lot of 20-somethings that don’t buy insurance now,” he said. They’ll be faced with the option of paying several hundred dollars per month versus 1 percent of income. “The polling is showing that a lot of those people are still going to opt out of the plan.”

Obamacare proponents point out that those 20-somethings likely will qualify for subsidies to reduce the premium.

■Some of the lingering confusion in Missouri

about Obamacare likely is a result of statewide elections in 2010 and 2012, when voters resound-ingly approved anti-Obamacare measures.

However, those votes were basically symbolic because they did not stop the federal health care law from being implemented, although Proposi-tion E, approved last November, certainly put up a barrier to starting the online marketplace.

Prop E, a statutory change proposed by the Gen-eral Assembly, prohibits the governor or any state agency from establishing or operating a state-based health insurance exchange “unless autho-rized by a vote of the people or the legislature.”

The law gives the General Assembly or any citi-zen the right to sue the governor or any state agency — or its workers — that attempts or helps to get the exchange going. As a result, Missouri became one of 35 states where the federal govern-ment is operating the exchange either alone or in partnership with the state.

Proposition C, approved by 71 percent of Mis-souri voters in 2010, marked the first time a state had successfully challenged Obamacare. Prop C was a rejection of the individual mandate of Obamacare that everyone must purchase health insurance or pay a fine, but the state law cannot trump federal law, so the provision — which was ruled constitutional by the U.S. Supreme Court — is still in effect.

Analysts who consider the effects of repealing Obamacare point to the myriad parts of the law already in place and the Supreme Court’s endorse-ment — although narrow — as factors that make a complete repeal highly unlikely.

Still, other delays have slowed implementation of the mandate for large employers and a new limit on out-of-pocket costs. A report last Novem-ber by the partisan Congressional Research Ser-vice, an arm of Republican Sen. Tom Coburn’s senate office, said the Obama administration had missed as many as one-third of the deadlines established by the new health care law.

And on Thursday, administration officials were quietly telling key interest groups to expect initial glitches signing up online for coverage. Sources told The Associated Press that small businesses will not be able to enroll online in the Small Busi-ness Health Options Program, or SHOP, starting Tuesday. Instead, business owners initially will have to mail or fax their information so that they can enroll.

Kayser predicted that development back in June when he answered “yes and no” to a question about whether he thought the exchanges would begin enrollment on Oct. 1.

“SHOP will happen, but not in the virtual mar-ketplace,” he said in June.

Also on Thursday, the Department of Health and Human Services told Hispanic groups that the Spanish-language version of its healthcare.gov website will be not be ready to handle enrollments for a few weeks. An estimated 10 million Latinos are eligible for coverage.

In Boone County, from the halls of city and county government and hospitals and health clin-ics, to the businesses and coffee shops, there still seem to be more questions about Obamacare than answers.

“The scariest part for me as a health care person is all the unknown factors that have not come to light yet,” said Kinkead, the Centralia pharmacist. “At this point, there’s so much misinformation out there. The last thing we want to do … is give the wrong information.”

Sait Serkan Gurbuz/St Joseph News Pressvia APU.S. Sen. Roy Blunt of Missouri, right, arrives in May at Heartland Health in St. Joseph to speak about the Aff ordable Care Act. Blunt has been critical of so-called Obamacare and wants to defund the law.

A dose of uncertaintyCONTINUED FROM 1C

Page 3: Diagnosis Confusion

6A www.columbiatribune.com COLUMBIA DAILY TRIBUNE Wednesday, October 2, 2013

If deter-If deter-mined mined eligible eligible for a for a fed-fed-eral tax eral tax credit, credit,

the appli-the appli-cant can shop cant can shop

and compare available and compare available health care plans avail-health care plans avail-able on the exchange.able on the exchange.

Enroll in a health care Enroll in a health care plan and potentially plan and potentially begin paying for pre-begin paying for pre-mium. Full coverage mium. Full coverage under the plan would under the plan would begin Jan. 1.begin Jan. 1.

A A person person decides decides to enroll to enroll in health in health insur-insur-ance ance through through the the

marketplace. You can apply marketplace. You can apply online, in person, by mail or online, in person, by mail or by phone.by phone.

Fill out Fill out applica-applica-tion for tion for insurance. insurance. The online The online form for form for a single a single person person takes takes

approximately 30 to 60 approximately 30 to 60 minutes to complete.minutes to complete.

Information is Information is entered into entered into the computer the computer system to de-system to de-termine eligibil-termine eligibil-ity. This could ity. This could be determined be determined in real time in real time or could take or could take

longer, depending on a longer, depending on a number of factors.number of factors.

HOW THE ENROLLMENT PROCESS IS SUPPOSED TO WORK

UNDECIDED:UNDECIDED: Additional Additional information is needed information is needed to determine eligibility.to determine eligibility.

APPROVED:APPROVED: Applicant Applicant is eligible to use health is eligible to use health care exchange system.care exchange system.

DENIEDDENIED: If not eligible,: If not eligible,the applicant applies for the applicant applies for coverage under Medicaid.coverage under Medicaid.

STEP FIVE: STEP SIX:STEP ONE: STEP TWO: STEP THREE: STEP FOUR:

DIAGNOSIS: CONFUSIONA HEALTH CARE SYSTEM IN TRANSITION

■ Compared to its neighbors, Missouri has fewer insurance carriers to choose from, fewer qualifi ed health plans to compare and higher premiums.

■ Coverage tiers range from bronze plans, which cover about 60 percent of medical costs, to platinum plans, which cover about 90 percent of costs.

■ Estimates indicate the average monthly premium for a middle-of-the road policy in Missouri is $334, slightly higher than the national average.

Missourians have limited options on the marketplace

BY JACOB [email protected] | 815-1722

Now that the health insur-ance exchanges are open, all you have to do is shop. In Missouri, that might not take as long as it will in neigh-boring states.

As the final outlines of Obamacare come into focus, there’s still a lot left to learn. But early indications from a U.S. Health and Human Services preview last week indi-cated Missouri, compared to its neighbors, has fewer insurance carriers to choose from and fewer qualified health plans to compare, as well as higher premiums.

The bigger problem now might be accessing a workable website to actually compare the plans. The launch of the exchanges yesterday was dogged by glitch-es. Tribune reporters were unable to log on throughout the day.

Regardless, the biggest provisions of the health care law signed by President Barack Obama three years ago are finally taking effect. Like any major policy overhaul, there are winners, losers and a learning curve.

People with pre-existing medical condi-tions no longer can be barred from pur-chasing insurance. Women can’t be charged more for insurance than men. People who got by without insurance on a bet they wouldn’t get sick or hurt will have to purchase it or pay a fine starting next year. Some companies are shaking up how they provide benefits, pushing spouses or other dependents off company insurance plans.

However, most Americans receive insur-ance through their employers, and for them, the change is expected to be mini-mal.

“I don’t think we’re going to have a mass exodus of employers providing coverage if they were providing it before,” said Debra Mathes, an accountant and owner at Mid-Missouri accounting firm Williams Keep-ers.

But there are big uncertainties sur-rounding Obamacare. One is whether it will do anything to tame the rising costs of medical care. Experts are skeptical, but they admit it does begin to move the sys-tem toward one that pays based on out-comes, not on the number of services rendered.

Another question is whether the ranks of the uninsured will be able to afford the new requirement to purchase health insur-ance. People earning between 100 percent and 400 percent of the federal poverty level ($11,490 to $45,960 for an individual) will qualify for government subsidies to help pay their monthly premiums. But that raises another question: How much will those subsidies eventually cost? In the first year, at least, the estimate is $16 bil-lion, according to the Robert Wood John-son Foundation.

Individual subsidies will vary, and they are calculated for you when you sign up for health insurance on the individual exchange.

“It’ll be paid directly to the insurance companies,” said Kit Wagar, a communi-cations official at U.S. Health and Human Services, or HHS, who spoke at a Cover Missouri conference in late August. “So the consumer doesn’t even have to worry about it.”

Despite the recent focus on the individ-ual insurance exchanges, the law is designed to keep employer-sponsored insurance as the lynchpin of the American health care system. Starting in 2015, many employers will be required to offer insur-ance or pay a fine. But for many people, there’s a steep learning curve ahead. The biggest challenge will be learning how to navigate the new exchanges — once they start working.

THE EXCHANGEThe health insurance exchanges, unique

to each state, are online marketplaces where consumers can shop for insurance

plans and easily compare prices — a new level of transparency in at least one por-tion of the opaque health care services market.

Answer a few questions about your age, where you live and lifestyle behaviors such as smoking, and you’ll be able to look at premiums (monthly payments for insur-ance) and deductibles (the out-of-pocket costs you pay before insurance kicks in) for health insurance plans offered in your state.

To better help consumers compare plans, they are supposed to be divided into easily comparable coverage tiers: bronze, silver, gold and platinum. Those plans range from covering about 60 percent of medical costs in a bronze plan to as much as 90 percent in a platinum policy.

In Missouri, relatively few insurers have signed up to sell policies on the exchange, which will primarily serve those who don’t get coverage through their employer. Only two have said they will sell plans, but that could change depending on how popular the exchanges become.

“The biggest incentive is going to be the success of the program,” Gary Cohen, a deputy administrator and director for the Centers for Medicare and Medicaid Ser-vices, said in a conference call with report-ers last week. “This is a marketplace. This is private commercial companies deciding whether they want to be a part of it or not.

Some have decided to sit back and see how it goes. Others have decided to jump in with both feet.”

THE PREMIUMSWhile technical problems on Missouri’s

federally run health exchange made it dif-ficult to compare plans, prices and pro-vider networks yesterday, a report from HHS last week gave an early indication of what the state’s residents can expect.

Insurers can still charge different rates depending on age, and in Missouri, the average monthly premium for a middle-of-the road health policy — the second-lowest-costing silver plan — was expected to cost around $334, slightly higher than the national average.

Comparing that price to existing premi-ums is difficult because health insurance plans offer different levels of coverage. Here’s a rough comparison: In 2011, the average monthly premium paid for employee coverage in Missouri was $400, according to a report released in April by the University of Minnesota and the Rob-ert Wood Johnson Foundation. Employees typically paid only about 20 percent of that. But that average takes into account all plans while the HHS estimate is for a middle-of-the-road policy that covers 70 percent of health care costs.

Data for average premiums that include those who buy on the individual market

are more difficult to find on a state-by-state basis. The National Conference of State Legislatures says no federal agency releases those figures on an annual basis. It cites a 2007 report from the Joint Eco-nomic Committee of Congress for recent state figures. That report says Missouri’s average annual premium in 2006 was $4,186, or about $349 a month. That num-ber has no doubt risen, but even in 2006, it was still higher than the average esti-mate for a silver plan on the new insur-ance exchange.

The estimates released by HHS tell only a portion of the story. While premiums might appear comparable, it’s still unknown how affordable the plans will be when taking into account deductibles and co-pays and the provider network of each plan. Some news reports suggest the low-er-than-expected premiums are a result of smaller provider networks.

Missouri seems to have higher premium costs than all of its neighbors except Arkansas. Average premiums for a silver benchmark plan in Illinois and Iowa are around $285. Kansas is at $260, and Okla-homa is at $266.

All of those states have more insurers participating in the exchange. In Illinois, some regions have as many seven insurers and 80 plans to choose from. Kansas has only three insurers in some regions of the state and two in others, but even in the places with two insurers, consumers will have as many as 36 plans to choose from, according to a report released by HHS last week.

Missouri, by contrast, has at most 23 plans to choose from (in the St. Louis area) and only two insurers expected to partici-pate in each of the state’s 10 regions.

“It’s just going to be really different state to state, even in regions of the state,” said Ryan Barker, vice president of health poli-cy at the Missouri Foundation for Health.

THE PROVIDERSIn Mid-Missouri, choices seem to be

more limited and premiums higher than in many areas of the state. Residents in

Boone, Cole, Callaway and other Mid-Missouri counties can expect to choose from only 18 plans from two insurers ini-tially, according to HHS.

One of those insurers is Anthem Blue Cross Blue Shield. It will include many Mid-Missouri health systems on its net-work, including University of Missouri Health Care, Moberly Regional Medical Center, Audrain County Medical Center and St. Mary’s Health Center.

It will not include Boone Hospital Cen-ter, operated by St. Louis-based BJC HealthCare, on its individual exchange plans, a spokeswoman confirmed. Nor will it include Lake Regional Medical Center in Osage Beach in its network for individual policies sold on the exchange. However, both health systems will be included in the small business marketplace, or SHOP.

A spokeswoman for Aetna, which owns Coventry Health Care, said Coventry of Missouri will provide eight plans in the region: four bronze plans, two silver plans and two gold plans. Coventry’s network will include Boone Hospital Center as well as University of Missouri Health Care.

In Mid-Missouri, a benchmark silver plan monthly premium for a 40-year-old would cost around $307 a month. In St. Louis, it would run about $263, and in Kansas City and Springfield it would be $238.

There are fewer lives to cover in Mid-Missouri and fewer providers to negotiate with than in the state’s more populous areas, said Thomas McAuliffe, a heath pol-icy analyst with the Missouri Foundation for Health.

“They can’t bargain for the rates they can in the urban areas,” he said.

More insurers that jump in as the exchanges mature might drive down health insurance rates. That might be the only way because it doesn’t look likely that new hospitals are going to start up in Columbia anytime soon.

“If there’s fewer providers in a given area, then there’s less to negotiate on because you have to have that provider,” Barker said.

Anne Lyon, left, talks yesterday with Brandi Hawkins about diff erent types of health insurance at the University of Arkansas Clinton School in Little Rock, Ark. State offi cials yesterday marked the launch of Arkansas’ insurance exchange, set up under the federal health care law.

Danny Johnston/AP

WHO ARE THE PROVIDERS?There are two confi rmed insurance carriers that cover Mid-Missourians on the There are two confi rmed insurance carriers that cover Mid-Missourians on the health insurance exchange. Aetna/Coventry will not participate in the small busi-health insurance exchange. Aetna/Coventry will not participate in the small busi-ness health insurance exchange, or SHOP, in 2014, but it will off er eight insurance ness health insurance exchange, or SHOP, in 2014, but it will off er eight insurance plans on the individual exchange. Anthem Blue Cross Blue Shield will include all plans on the individual exchange. Anthem Blue Cross Blue Shield will include all of the health systems below in its SHOP network, but Boone Hospital Center and of the health systems below in its SHOP network, but Boone Hospital Center and Lake Regional Health System will not be in its network on policies sold on the Lake Regional Health System will not be in its network on policies sold on the individual exchange. individual exchange. �University of Missouri Health Care (University Hospital and Capital Region Medi-University of Missouri Health Care (University Hospital and Capital Region Medi-cal Center in Jeff erson City): Coventry and Anthemcal Center in Jeff erson City): Coventry and Anthem�Boone Hospital Center: CoventryBoone Hospital Center: Coventry�SSM Health Care (St. Mary’s Health Center in Jeff erson City and Audrain Medical SSM Health Care (St. Mary’s Health Center in Jeff erson City and Audrain Medical Center in Mexico): Coventry and AnthemCenter in Mexico): Coventry and Anthem�Moberly Regional Medical Center: Anthem. Coventry unknown. Moberly Regional Medical Center: Anthem. Coventry unknown. �Lake Regional Health System: CoventryLake Regional Health System: Coventry

Page 4: Diagnosis Confusion

Vanessa Hall does not pay for health insurance because of the cost. She has found out that she does not qualify for subsidies under Obamacare, but she’s a fan of the program anyway and sees it as a good “fi rst step” toward a single-payer system.

Ryan Henriksen/Tribune

FYI

Wednesday, October 2, 2013 COLUMBIA DAILY TRIBUNE www.columbiatribune.com 7A

YESTERDAY: How does the health insurance marketplace work, and what coverage options do Missourians have?

TODAY: How many newly insured people will there be, and does Mid-Missouri have enough providers to meet demand?

COMING TOMORROW: The Missouri General Assembly con-tinues looking at Medicaid expan-sion. What are the prospects?

COMING SATURDAY: Even though the exchange for small businesses was delayed, business owners face tough choices.

WHAT DOES THAT MEAN?

Obamacare has many terms — some Obamacare has many terms — some old, some new — that are worth becom-old, some new — that are worth becom-ing familiar with.ing familiar with.Premium tax credits:Premium tax credits: An amount that An amount that can be subtracted from the amount of can be subtracted from the amount of income tax a person or business owes. income tax a person or business owes. Premium tax credits will be off ered to Premium tax credits will be off ered to some individuals and small businesses some individuals and small businesses that purchase health coverage through that purchase health coverage through Health Insurance Marketplaces to help Health Insurance Marketplaces to help pay for the cost of coverage. You can pay for the cost of coverage. You can have the tax credit applied to your have the tax credit applied to your premium over the course of the year or premium over the course of the year or wait until you fi le your taxes to claim wait until you fi le your taxes to claim the full amount.the full amount.SHOP: SHOP: Small Business Health Options Small Business Health Options

Program, a new program designed to Program, a new program designed to simplify the process of fi nding a health simplify the process of fi nding a health plan for a small business, generally plan for a small business, generally those with 50 or fewer employees. those with 50 or fewer employees. SHOPs are competitive marketplaces SHOPs are competitive marketplaces where small employers can go to fi nd where small employers can go to fi nd health coverage from a selection of health coverage from a selection of providers. The small business tax credit providers. The small business tax credit is available only through a SHOP.is available only through a SHOP.Tax credits:Tax credits: Government health insur- Government health insur-ance subsidies for individuals will come ance subsidies for individuals will come in the form of tax credits. The money in the form of tax credits. The money will be paid directly to the consumer’s will be paid directly to the consumer’s health plan to help cover premiums. The health plan to help cover premiums. The subsidies are on a sliding scale based subsidies are on a sliding scale based on income. Each year, people will have on income. Each year, people will have to “true up” with the Internal Revenue to “true up” with the Internal Revenue

Service to make sure they got the right Service to make sure they got the right amount. People who receive too gener-amount. People who receive too gener-ous a tax credit might owe money back ous a tax credit might owe money back to the government.to the government.Tax penalty: Tax penalty: The fi ne levied on individu-The fi ne levied on individu-als who disregard the individual insur-als who disregard the individual insur-ance mandate. It starts small and gets ance mandate. It starts small and gets bigger in subsequent years. In 2014, it’s bigger in subsequent years. In 2014, it’s $95 or 1 percent of taxable income. By $95 or 1 percent of taxable income. By 2016, it’s $695 or 2.5 percent of taxable 2016, it’s $695 or 2.5 percent of taxable income, whichever is greater. Thereafter, income, whichever is greater. Thereafter, it’s adjusted for infl ation.it’s adjusted for infl ation.

Sources: Department of Health and Hu-Sources: Department of Health and Hu-man Services, Blue Cross Blue Shield, The man Services, Blue Cross Blue Shield, The Associated Press, Kaiser Family Founda-Associated Press, Kaiser Family Founda-tion, younginvincibles.orgtion, younginvincibles.org

☎ | WHOM TO CONTACT

Information from the federal government about Missouri’s Information from the federal government about Missouri’s marketplacemarketplace can be found at www.healthcare.gov or by can be found at www.healthcare.gov or by calling 800-318-2596. calling 800-318-2596. Primaris Health Business Solutions: Primaris Health Business Solutions: For individual coun-For individual coun-seling in Mid-Missouri, call 573-817-8300 or log on to seling in Mid-Missouri, call 573-817-8300 or log on to www.primaris.org/counseling. Program director: Jeremy www.primaris.org/counseling. Program director: Jeremy MilarskyMilarskyCentral Missouri Community Action’s health care/Obama-Central Missouri Community Action’s health care/Obama-care hotline:care hotline: 855-612-2259 855-612-2259Family Health Center of Boone County,Family Health Center of Boone County, 1001 W. Worley 1001 W. Worley St., Aaron Swaney, 877-677-4342St., Aaron Swaney, 877-677-4342Central Missouri Area Agency on Aging, Central Missouri Area Agency on Aging, 1121 Business 1121 Business Loop 70 E., Jean Leonatti, 800-369-5211, www.cmaaa.netLoop 70 E., Jean Leonatti, 800-369-5211, www.cmaaa.netAlso:Also: www.ma4web.org/health-insurance-marketplace- www.ma4web.org/health-insurance-marketplace-missouri/local-resourcesmissouri/local-resources

Grandmother sees law as step on way to further reformsBY JACOB [email protected] | 815-1722

For the past 20 years, Vanessa Hall has been without health insurance.

It was a financial decision, and a good one, she said, to stop pay-ing for a plan that cost a lot and provided little in the way of cov-erage. It hasn’t stopped her going to the doctor. She regularly gets preventative exams and buys generic prescriptions out of pocket.

“It’s reasonable,” she said. “It’s not much more than a co-pay in all reality.”

She pays with cash, and doc-tors give her a steep discount. Because the money is upfront, they don’t have to go through insurance company middlemen that are a mainstay of the Ameri-can health care system and will be even further embedded by Obamacare.

“That discount tells you how much overhead and profit is involved,” Hall said.

It has been affordable, Hall said. But she worries that soon, it won’t be. In her home off Route WW, just over the line into Calla-way County, she stands in her kitchen with the help of a cane. Several years ago, she hurt her back when a swivel chair “swiv-eled one way and I swiveled another.” Sliding down the stairs with her grandson on her lap — a game they called “bump bump” — probably didn’t help, either.

“I miss sitting on the floor because I can’t do that anymore,” Hall said. “And it’s very hard to work in the garden. But I’m so much better off than most peo-ple.”

She has managed to pay for services to manage pain out-of-pocket. But she knows if it keeps getting worse, she won’t be able to afford a major service such as an operation. And she also knows that Obamacare requires her to purchase insurance starting Jan. 1. If she doesn’t, she’ll pay a fine of at least $95 the first year; the penalty quickly rises to at least $695 by 2016.

Hall’s husband works. He has a good job, and they live comfort-ably with their 12-year-old grand-son, Matthew. When Matthew came into their care 12 years ago, Hall stopped substitute-teaching to raise him. They had enough to live as a one-income household.

Hall’s husband’s job provides insurance for him and Matthew. It’s pretty good insurance and affordable for them, Hall said. But if she wanted to be included on the policy, it wouldn’t be. She

estimated premiums for cover-age that included her would cost close to 20 percent of the house-hold’s income.

Obamacare provided Hall with the prospect of help. The law offers subsidies to help families making as much as 400 percent of poverty buy health insurance. A family of three making less than $78,000 a year would be eli-gible for help. Hall said her family would qualify.

But Obamacare only provides subsidies to purchase insurance on the exchange if a family isn’t offered “affordable” coverage from an employer. “Affordable” is defined as less than 9.5 percent of family income. But that calcu-lation is based on what it costs a single employee to buy coverage, not what it would cost a family to purchase insurance. The insur-ance her husband can purchase would qualify as affordable, meaning she won’t get any help from the new law.

Hall knows she could go hunt for a job, but she doubts she would find a very good one after being out of the workforce for more than a decade and nearing 60 years of age. With her back problems, she could probably qualify for disability, but she doesn’t want to draw taxpayer funds her family can afford to live without. After all, she is only eight years away from Medicare eligibility.

Personally, Hall is a supporter of health care reform, even though she found out it won’t help her to afford insurance. The best answer Hall sees is single-payer, and she hopes Obamacare eventually leads to more reform of the health care system.

“I’m for this because it’s a step forward,” Hall said, “but it’s a first step.”

State opposition set roadblocks to health insurance exchangeBY JACOB [email protected] | 815-1722

Obamacare has arrived in the Show-Me-State — despite the best efforts of many of its residents.

Some provisions have already started, such as allowing young people to stay on their parents’ insurance until they’re 26. Others the state rejected, such as expand-ing Medicaid to cover people with incomes of as much as 138 percent of the federal poverty level.

But the law’s centerpiece, the establishment of online health insurance marketplaces where consumers can shop and compare insurance policies, officially opened yesterday.

Missouri is one of 36 states where the federal government will have a role operating the insur-ance exchange. Unlike some states that partnered with the federal government, Missouri was one of the states that ceded all control to the feds.

It also put up roadblocks to the law’s implementation, including a voter-approved measure that barred state officials from any involvement in getting the exchange up and running.

As a result, spreading the word about Missouri’s exchange has been put in the hands of private groups. While other states distrib-ute swag such as sunscreen that says “get covered” to promote their exchanges, Missouri’s government has stayed silent.

“The Department of Insurance is not promoting the exchanges in

any way, shape or form,” said Bridget Kevin-Myers, an assistant research professor and senior legal analyst in the University of Mis-souri’s Institute of Public Policy.

In January, Kevin-Myers authored a legal brief on Proposi-tion E, which was passed by the Republican-controlled General Assembly and approved by Mis-souri voters in November with 62 percent of the vote.

“Missouri agencies, their employees and officials are exposed to potential litigation if they assist, cooperate or provide any resources to any department,

agency or employee of the federal government related to a federal exchange or a federally facilitated exchange,” she wrote.

Missouri regulates insurance within its boundaries, and the law could keep the Department of Insurance from approving new insurance plans to be sold on the exchange out of fear they will be sued, Kevin-Myers argues. That likely means the carriers partici-pating will be those already oper-ating in the state.

Getting the word out has fallen to private groups. The main one, Cover Missouri, is a coalition of community and health care pro-vider groups put together by the Missouri Foundation for Health. It became clear earlier this year that the foundation would have to step up and take the lead to let Missou-rians know what resources and financial aid was available, who qualifies for insurance on the exchange and how to access it, said Ryan Barker, the foundation’s vice president for health policy.

But the Missouri Foundation for Health doesn’t have the clout state government does, and it has relied more on a grass-roots campaign to raise awareness of the changes Obamacare is bringing to Missouri.

“Even, like, Kansas, the insur-ance commissioner — the Repub-lican insurance commissioner — she’s been out there” promoting the Kansas exchange, he said. “A lot of people go to government for information. None of that’s avail-able in Missouri.”

Early indications show that Mis-souri will have fewer insurance carriers than many states selling insurance on the exchange — just two in most areas of the state. Many of Missouri’s neighbors have more insurers offering plans, and on average, they’re cheaper.

Has the lack of outreach and legal questions about the ability of Missouri’s insurance regulators to approve new plans discouraged some insurers from selling on the exchange? It’s hard to tell.

“If we didn’t have Prop E, would we have seen more” insurance car-riers? “I don’t know,” Barker said.

Proposition E could be playing a part in the small number of insur-ance carriers interested in Mis-souri. But, more likely, it is the health of Missouri’s residents, Kev-in-Myers said. Missouri has some of the highest smoking and obesity rates in the country.

“It could be” Proposition E, she said. “It could also be more so the health status. Colorado has a lot. They have 11 carriers, but it’s also one of the healthier states.”

There have been no lawsuits — that she knows of — filed using Proposition E, Kevin-Myers said. In any case, federal law trumps state law, and any lawsuits likely would be decided in favor of state officials following federal law. Still, it would cost Missouri time and money defending against them.

“Missourians may be required to fund futile litigation to defend a statue that is likely to be struck down,” she wrote in her brief.

Missouri agencies,

their employees and offi cials are exposed to potential litiga-tion if they assist, cooperate or provide any resources to any department, agency or employee of the federal government related to a federal exchange or a feder-ally facilitated ex-change.”

— BRIDGET KEVIN-MYERS,

MU assistant research professor

h i

VANESSA HALLAGE: 5757OCCUPATION: None. Hall None. Hall stays at home to raise her stays at home to raise her 12-year-old grandson12-year-old grandsonCURRENT INSURANCE SITUATION: Uninsured; Uninsured; husband is covered under a husband is covered under a policy off ered by employerpolicy off ered by employerHOW WOULD AFFORD-ABLE CARE ACT AFFECT HER: It doesn’t. Obamac-It doesn’t. Obamac-are provides subsidies to are provides subsidies to purchase insurance on the purchase insurance on the exchange if a family isn’t exchange if a family isn’t off ered “aff ordable” care. off ered “aff ordable” care. Insurance her husband can Insurance her husband can purchase qualifi es as aff ord-purchase qualifi es as aff ord-able, meaning she won’t get able, meaning she won’t get any help from Obamacare.any help from Obamacare.

Q&AHOW DO THE SUBSIDIES WORKIf you make between 100 If you make between 100

percent and 400 percent of the percent and 400 percent of the federal poverty level ($11,490 to federal poverty level ($11,490 to $45,960 for an individual), then $45,960 for an individual), then you could qualify for subsidies you could qualify for subsidies from the federal government to from the federal government to help you pay for health insur-help you pay for health insur-ance. The subsidies would be ance. The subsidies would be paid directly from the govern-paid directly from the govern-ment to the insurance company. ment to the insurance company. To qualify, you must purchase To qualify, you must purchase insurance on an exchange and insurance on an exchange and not be off ered insurance from not be off ered insurance from your employer that is consid-your employer that is consid-ered “aff ordable” (the coverage ered “aff ordable” (the coverage must not cost more than 9.5 must not cost more than 9.5 percent of your income, and it percent of your income, and it must cover 60 percent of health must cover 60 percent of health benefi ts). benefi ts).

Calculating your benefi t is a Calculating your benefi t is a little tricky, but it’s best to think little tricky, but it’s best to think of it as the diff erence between a of it as the diff erence between a mid-level health plan and a per-mid-level health plan and a per-centage of your income that you centage of your income that you will be responsible for paying for will be responsible for paying for health insurance premiums. health insurance premiums.

EXAMPLE 1: A SINGLE 24-YEAR-OLD WITH NO DEPENDENTS EARNING $28,725 A YEARYou are a single person, age 27, with no dependents who You are a single person, age 27, with no dependents who makes $28,725, (two times the poverty rate for a family of one). makes $28,725, (two times the poverty rate for a family of one). 1. 1. Take 6.3 percent of your income, or $151 per month. Take 6.3 percent of your income, or $151 per month. 2. 2. The federal government calculates your subsidy against The federal government calculates your subsidy against a middle-of-the-road plan, or the second-lowest-costing a middle-of-the-road plan, or the second-lowest-costing “silver” plan, which covers at least 70 percent of health “silver” plan, which covers at least 70 percent of health costs. In Mid-Missouri, the second-lowest costing silver costs. In Mid-Missouri, the second-lowest costing silver

plan is estimated to cost about $252 per month for a plan is estimated to cost about $252 per month for a 27-year-old. 27-year-old. 3. 3. Subtract $151 from $252. Your subsidy is $101 Subtract $151 from $252. Your subsidy is $101 per month and will be sent directly from the gov-per month and will be sent directly from the gov-ernment to the insurer. ernment to the insurer.

4. 4. You can purchase that silver plan for $151 You can purchase that silver plan for $151 a month, or you can apply that $101 subsidy a month, or you can apply that $101 subsidy to another plan, such as a lower-premium to another plan, such as a lower-premium bronze plan that will only cover about 60 bronze plan that will only cover about 60 percent of your health costs or a higher-percent of your health costs or a higher-premium gold plan that will cover 80 premium gold plan that will cover 80 percent. percent. 5. 5. The lowest-costing bronze plan in Mid-The lowest-costing bronze plan in Mid-Missouri runs about $195 for a 27-year-old, Missouri runs about $195 for a 27-year-old, so you could buy that for $94 a month. so you could buy that for $94 a month. A gold plan would cost $298 without the A gold plan would cost $298 without the subsidy, but at your income, you could buy subsidy, but at your income, you could buy it for $197 a month. it for $197 a month.

EXAMPLE 2: A FAMILY OF FOUREARNING $50,000 A YEAR Your household (a 40-year-old, a 38-year-old and two kids Your household (a 40-year-old, a 38-year-old and two kids younger than 18) makes $50,000 a year, or just more than younger than 18) makes $50,000 a year, or just more than twice the poverty rate.twice the poverty rate.1. 1. A benchmark silver health plan costs $798 a month in A benchmark silver health plan costs $798 a month in Missouri. Missouri. 2. 2. Take 6.8 percent of income, or $282 a month. Take 6.8 percent of income, or $282 a month. 3. 3. Your credit would be $516 per month, the diff erence be-Your credit would be $516 per month, the diff erence be-tween the second-lowest-costing silver plan and 6.8 percent tween the second-lowest-costing silver plan and 6.8 percent of your income. of your income.

4. 4. The average lowest-costing The average lowest-costing bronze plan in Missouri would bronze plan in Missouri would run $588. If you used your tax run $588. If you used your tax

credit, you could buy it for credit, you could buy it for $72 per month.$72 per month.

Income level as percentage of federal poverty levelIncome level as percentage of federal poverty level Premium costs as a percentage of incomePremium costs as a percentage of income

Less than 133 percent of poverty levelLess than 133 percent of poverty level 2 percent of income2 percent of income

At least 133 percent but less than 150 percent At least 133 percent but less than 150 percent 3 to 4 percent of income3 to 4 percent of income

At least 150 percent but less than 200 percent At least 150 percent but less than 200 percent 4 to 6.3 percent of income4 to 6.3 percent of income

At least 200 percent but less than 250 percent At least 200 percent but less than 250 percent 6.3 to 8.05 percent of income6.3 to 8.05 percent of income

At least 250 percent but less than 300 percent At least 250 percent but less than 300 percent 8.05 to 9.5 percent of income8.05 to 9.5 percent of income

At least 300 percent but less than 400 percentAt least 300 percent but less than 400 percent 9.5 percent of income9.5 percent of income

WHO QUALIFIES FOR A SUBSIDY AND HOW MUCH?

FAMILY FAMILY SIZE:SIZE:

YEARLY:YEARLY: MONTHLY:MONTHLY: HOURLY:HOURLY:100% of FPL100% of FPL 400% of FPL400% of FPL 100% of FPL100% of FPL 400% of FPL400% of FPL 100% of FPL100% of FPL 400% of FPL400% of FPL

1 $11,490$11,490 $45,960$45,960 $958$958 $3,832$3,832 $5.52$5.52 $22.10$22.10

2 $15,510$15,510 $62,040$62,040 $1,293$1,293 $5,172$5,172 $7.46$7.46 $29.83$29.83

3 $19,530$19,530 $78,120$78,120 $1,628$1,628 $6,510$6,510 $9.39$9.39 $37.56$37.56

4 $23,550$23,550 $94,200$94,200 $1,963$1,963 $7,850$7,850 $11.32$11.32 $45.29$45.29

5 $27,570$27,570 $110,280$110,280 $2,298$2,298 $9,190$9,190 $13.25$13.25 $53.02$53.02

6 $31,590$31,590 $126,360$126,360 $2,633$2,633 $10,530$10,530 $15.19$15.19 $60.75$60.75

INCOME COMPARED TO THE 2013 FEDERAL POVERTY LEVEL

Page 5: Diagnosis Confusion

Are we readTechnical problems block access to health insurance marketplace. BY JACOB [email protected] | 815-1722

Many of the people who are sup-posed to help the uninsured compare health coverage options on the exchange are ready to go. The exchange, however, isn’t.

Technical problems with the new health insurance market-

places persisted into this morning. Tribune reporters were unable to create an account and log on to health-care.gov, which is necessary to view plan options and costs.

Various agencies around Columbia are training spe-cialists to help people shop and compare insurance poli-cies, and they reported some inquiries about the new exchanges. One agency said calls from reporters out-numbered those from people seeking information about health insurance.

But for those who did call inquiring about new options from the Affordable Care Act, the Central Missouri Area Agency on Aging is having them wait until next week to meet with one of their enrollment specialists. The agen-cy’s parent group, the Missouri Association of Area Agen-cies on Aging, was awarded a $750,000 grant in August to train enrollment specialists — dubbed navigators — and organize outreach events.

“We learned from Medicare Part D you don’t want to be the first one out there,” Jean Leonatti, CEO of the Cen-tral Missouri agency, said yesterday.

About 10 people called, a few sent emails and three walked into the Family Health Center of Boone County on Tuesday seeking information and help with the new insurance exchange, said Aaron Swaney, an outreach and enrollment specialist at the health center. But because the site wasn’t working, there wasn’t much he and his staff could do except tell people they would contact them when the system was working.

“We’re just taking down people’s contact information,” he said yesterday morning.

■At Primaris, a Columbia health consulting not-for-

profit, more than 70 navigators began the required train-ing for the job, and 27 are already through the process, said Jeremy Milarsky, the navigator program manager. Primaris is coordinating a statewide navigator program with 10 other partner agencies with the help of a $1 mil-lion federal grant. The few navigators who are already working in Columbia have had steady inquiries about the exchange, Milarsky said.

“I think people are still trying to feel out the system,” he said. “We’re not getting inundated with calls. There’s a steady stream of them.”

People were mostly patient despite the technical issues, and he did have a breakthrough: “As of” yesterday

“afternoon, I was actually able to get an account created for one of my clients,” Milarsky said.

Even before the official launch of the health insurance

exchanges, a centerpiece osigned into law three years agcups were likely.

6A www.columbiatribune.com COLUMBIA DAILY TRIBUNE Thursday, October 3, 2013

■ Various agencies in Columbia are training specialists to help people shop and compare insurance policies, and they reported some inquiries about the new health insurance marketplace.

■ Although many of the peohelp the uninsured compareon the exchange were readysite used to enroll people wa

A: A: First of all, the marketplace fea-First of all, the marketplace fea-tures health insurance plans off ered by a tures health insurance plans off ered by a variety of private insurance companies. It variety of private insurance companies. It is not government-run health insurance, is not government-run health insurance, though the government sets the stan-though the government sets the stan-dards the plans must meet.dards the plans must meet.

Whether you have the same doctor as Whether you have the same doctor as you have now depends on which plan you have now depends on which plan you purchase and which plans your doc-you purchase and which plans your doc-tor participates in. The marketplaces, or tor participates in. The marketplaces, or exchanges, could include plans that re-exchanges, could include plans that re-

duce the number of doctors or hospitals duce the number of doctors or hospitals covered in certain networks. covered in certain networks.

The American Medical Association sug-The American Medical Association sug-gests that people check out plans on the gests that people check out plans on the exchanges before buying to make sure exchanges before buying to make sure their preferred docs are included. Naviga-their preferred docs are included. Naviga-tors and enrollment counselors, as well as tors and enrollment counselors, as well as insurance agents and brokers, are trained insurance agents and brokers, are trained to help you avoid that possibility and to to help you avoid that possibility and to help you maintain continuity of care. help you maintain continuity of care.

Q&A WHO CHOOSES YOUR DOCTOR?

Q: I’VE HEARD THAT THE FEDERAL GOVERNMENT WILL CHOOSE

THE DOCTORS FOR PEOPLE WHO PURCHASE HEALTH INSURANCE

THROUGH THE ONLINE MARKETPLACE. IS THAT TRUE?

DIAGNOSIS: CONFUSIONA HEALTH CARE SYSTEM IN TRANSITION

FYIWHAT DO

Obamacare has many terms — some old, Obamacare has many terms — somsome new — that are worth becoming familiar some new — that are worth becomwith.with.Premium tax credits:Premium tax credits: An amount that can An amount tbe subtracted from the amount of income be subtracted from the amount oftax a person or business owes. Premium tax tax a person or business owes. Precredits will be off ered to some individuals and credits will be off ered to some indsmall businesses that purchase health cover-small businesses that purchase heage through Health Insurance Marketplaces age through Health Insurance Marto help pay for the cost of coverage. You can to help pay for the cost of coveraghave the tax credit applied to your premium have the tax credit applied to youover the course of the year or wait until you over the course of the year or waitfi le your taxes to claim the full amount.fi le your taxes to claim the full amoTax credits:Tax credits: Government health insurance Government health insubsidies for individuals will come in the form subsidies for individuals will comeof tax credits. The money will be paid directly of tax credits. The money will be pto the consumer’s health plan to help cover to the consumer’s health plan to h

17,859The number of uninsured people in The number of uninsured people in Boone County in 2012, according to Boone County in 2012, according to the U.S. Census Bureau’s American the U.S. Census Bureau’s American Community Survey.Community Survey.

4,001The number of uninsured people The number of uninsured people who will not qualify for premium who will not qualify for premium subsidies (those below the poverty subsidies (those below the poverty line)line)

Uninsured people between 100 per-cent and 400 percent of poverty, potentially qualifying for subsidies to purchase insurance on the ex-change

Boone County residents earn less than 138 percent of poverty and are uninsured. (These people would have qualifi ed for Medicaid expan-sion, excluding most students who likely still have coverage from their parents)

The total number of uninsured from sur-rounding Mid-Missouri counties, accord-ing to U.S. Census Small Area Health Insurance Estimates

BY THE NUMBERS | UNINSURED IN BOONE COUNTY

LOOKING TO THE WEST | IMPLEMENTATION IN KANSAS

Rogena Johnson, left, chief medical offi cer at PrairieStar Health Center in Hutchinson, Kan., answers questions for Jennifer Garcia after an examination at the center Sept. 25. PrairieStar will have certifi ed application counselors to help people who need assistance in applying for health care on the marketplace.

Tim Goessman/The Hutchinson News, AP

Kansas officials urge patience as glitches abound

WICHITA, Kan. (AP) — The online insurance marketplace for Kansas could not fully handle the crush of consumers who hit the federally run exchange when enrollment opened Tuesday, but the technological glitches were expected as not only the website but the program itself tried to keep up with demand.

On the first day of the six-month open enrollment period, advocates in Kansas were strug-gling to implement their own portion of the nation’s biggest health care coverage expansion in 50 years. The latest U.S. Cen-sus bureau estimates are that about 358,000 Kansans have no health insurance.

The Kansas Association for the Medically Underserved, the lead agency for the rollout in Kansas, said it had 60 health care naviga-tors or certified application counselors — the program’s front-line guides for the new sys-tem — across the state ready to work on the first day of enroll-ment. Another 200 to 225 more were still undergoing training to work, said KAMU spokeswoman Katrina McGivern. Six of those were bilingual in Spanish, and one person knew sign language.

At GraceMed Health Clinic in Wichita, a steady stream of peo-ple showed up for one-on-one sessions with Juven Nava, one of the clinic’s two navigators. The clinic has a grant that will allow it to hire two more navigators. By mid-day Tuesday, Nava had seen eight people at the clinic and taken about a dozen calls from people seeking to enroll in the state’s exchange.

But Nava has been unable to sign up a single person for insur-ance coverage. Sometimes he can’t even log into the website to sign them up; sometimes the online exchange kicks him off.

“We tell them that with every-thing there is going to be some glitches,” he said. “There is always going to be some bumps, but it is going to get better.”

GraceMed’s chief executive, Dave Sandford, said that when he tried to get access to the site, he got a message to wait because of the high volume, but after waiting 10 minutes, he was kicked off. He does not think anything could have been done to handle the significant volume of calls the site was going to get on Day One. “There are probably a lot of folks like me, who already have health insurance, that are

just trying to log on to see how it works,” Sandford said. “I am probably compounding the problem.”

At the Shawnee County Health Agency in Topeka, enrollment coordinator Paige Ashley said she, too, couldn’t obtain the online login she needed to purchase cov-erage on the site. She was advising people who were calling her to set up appointments to wait until at least next week.

Consumers won’t start incur-ring tax penalties for not having coverage until after March 31 of next year and have until Dec. 15 if they want their coverage to start in January.

U.S. Rep. Tim Huelskamp, a Republican who has been a vocal critic of the health care overhaul, said he tried unsuccessfully 20 times to get into the exchange. Huelskamp, who represents the sprawling and GOP-leaning First District of western and central Kansas, said he has been unable to even create the account that would allow him to purchase insurance. Members of Congress are required by the Affordable Care Act to use the exchange.

The federal government is running Kansas’ exchange because Republican Gov. Sam Brownback and the GOP leaders of the Legislature have resisted implementing the Affordable Care Act since its passage three years ago. They have argued that it represents a costly expansion of government.

Manuela Oroteza, a 48-year-old cook at Wichita State Univer-sity, said she was eager to see if she could afford health care through the new exchange. Her family lives off her $10-per-hour salary and can’t afford the cover-age the school offers its employ-ees. “The thing is, I don’t make that much money, and then between taxes and the insurance, my paycheck will not be enough to cover my expenses,” she said.

As has been the case in many other Republican-led states, Brownback and Kansas’ Republi-can legislative leaders have left it to the federal government to set up the Kansas exchange. In 2011, Brownback refused a $31.5 mil-lion federal grant that would have gone toward setting up the infrastructure for Kansas’ exchange. It also would have funded a $10 million public edu-cation campaign Insurance Com-missioner Sandy Praeger had planned.

Kansas Insurance Commissioner Sandy Praeger answers questions from audience members Sept. 17 after a town hall meeting on the federal health care overhaul at the University of Kansas satellite campus in Overland Park, Kan.

John Hanna/AP

Monica Craig, insurance counselor, works yesterday at Primaris, a Columbia heatrain counselors to help people enroll in health insurance through the new marsteady stream of inquiries about the exchange.

BY JACOB [email protected] | 815-1722

Outside the Family Health Center of Boone County on Worley Street, Kelly Camp was walk-ing out after having her hand examined for what she thinks might be carpal tunnel. Her other hand was full of informational pam-phlets on the new health insurance market-places created by Obamacare.

“I may look into it and speak with someone,” she said.

But Camp, like many Missourians, might be out of luck. The 51-year-old was laid off from 3M last month, and even though she doesn’t have any income right now, she was already told she wouldn’t qualify for Missouri’s Medic-aid program. Missouri’s current Medicaid sys-tem doesn’t offer coverage for low-income adults without dependent children.

Despite an offer from the federal govern-ment to pay the full cost for three years, Mis-souri legislators declined to expand Medicaid to cover people earning as much as 138 per-cent of the federal poverty level, or $15,862 for a household of one.

Obamacare was designed to provide insur-ance for low-income people via Medicaid while helping those with more moderate incomes purchase private health insurance on the online exchange with federal subsidies. A Supreme Court ruling last year upheld the law but said the federal government couldn’t force states to expand Medicaid. As a result, many

states led by Republicans opposed to Obamac-are didn’t expand it, leaving a big hole in the near-universal insurance coverage the law envisioned.

To qualify for subsidies to help purchase insurance on the exchange, you have to make more than the federal poverty level. There are approximately 245,000 uninsured Missouri-ans below the poverty line, according to the U.S. Census Bureau’s 2012 American Com-munity Survey released last month. In Boone County, about 4,000 people make less than the federal poverty rate and have no health insurance.

They have little hope of getting insurance unless they find a higher-paying job or the General Assembly expands Medicaid. When they seek help from one of the various agencies aiding those looking to buy insurance, there’s little to be found.

“It’s an unfortunate message of, ‘There’s not much we can do,’ ” said Ryan Barker, vice president of health policy for the Missouri Foundation for Health.

Camp, though, has more pressing worries

Woman doesn’t qualify for sKELLY CAMPAGE: 5151OCCUPATION: Unemployed. Camp was Unemployed. Camp was laid off from 3M last month.laid off from 3M last month.CURRENT INSURANCE SITUATION: No No insurance. Camp does not qualify for Mis-insurance. Camp does not qualify for Mis-souri’s current Medicaid system.souri’s current Medicaid system.HOW WOULD AFFORDABLE CARE ACT AFFECT HER: Without a source Without a source of income, Camp does not qualify for of income, Camp does not qualify for subsidies to purchase health care on the subsidies to purchase health care on the exchange. In addition, Missouri’s current exchange. In addition, Missouri’s current Medicaid system doesn’t off er coverage Medicaid system doesn’t off er coverage for low-income adults without dependent for low-income adults without dependent children, such as Camp.children, such as Camp.

Page 6: Diagnosis Confusion

dy for this?

of the Affordable Care Act go, officials warned that hic-

“We anticipate that our experience will mirror that of other large-scale implementation efforts,” Julie Bataille, director of communications at the Centers for Medicare

and Medicaid Services, said in a conference call with reporters last week.

It might be best to wait a month or so before trying to sign up for insurance, said Thomas McAuliffe, a policy analyst at the Missouri Foundation for Health. Not only will that give time for the federal government to fix glitches in the exchange system, but it will give the navi-gators time to get better at their jobs.

“You have until Dec. 15 to purchase insurance to begin on Jan. 1,” he said. “Why not wait until Nov. 1?”

■There are a lot of Missourians who will have to pur-

chase insurance or pay a fine starting next year. Of the roughly 850,000 uninsured Missourians, about 245,000 are below the poverty line and will not be required to purchase insurance. They also won’t qualify for subsidies to help them purchase health insurance on the exchang-es because the law envisioned all states expanding Med-icaid. Missouri did not.

Most of the uninsured making more than the pov-erty level will qualify for subsidies to help them buy coverage on the exchange. Anyone who isn’t offered affordable insurance from an employer and makes between 100 percent and 400 percent of the poverty level, or $19,530 to $78,120 for a family of three, would qualify for subsidies. Of the roughly 18,000 people without health insurance in Boone County, about 12,000 could qualify for subsidies, according to U.S. Census data.

Whether the new exchanges will lead to a crush of new patients at doctors’ offices is unknown, but many think it will be more of a trickle. The largest portion of uninsured Missourians are young, and they tend to be healthier.

“More importantly, it’s going to be getting those patients enrolled,” said University Physicians Executive Director Scott Hofferber.

The physicians group estimates it could see as many as 7,000 new patients because of insurance expansion, Hofferber said. He thinks it will be gradual, and at any rate, University Physicians has beefed up its staff, espe-cially primary care doctors, just in case.

“We’ve added primary care over the last couple of years, so I think we’re ready for that,” he said.

■Until the feds fix the exchange website, the uninsured

will almost surely obtain coverage in a trickle. Those frus-trated by the system could give up.

But even before the problems were evident, Gary Cohen, a deputy administrator at the Centers for Medi-care and Medicaid Services, told reporters on a confer-ence call that initial problems aren’t a good indicator of popularity.

“What I like to remind people of is what happened when we introduced Medicare Part D,” he said. “There were really significant problems in the early days and weeks and months.”

Today, it’s not remembered as “the program that had all the problems,” he said. Seniors like it. The new exchanges, like any software or system, can be updated and improved over time.

“Any big IT project, there are always going to be things you can improve on and make better,” Cohen said.

ople who are supposed to e health coverage options y to go Tuesday, the web-as not.

■ Some offi cials are urging people to wait before try-ing to sign up for insurance on the marketplace. “You have until Dec. 15 to purchase insurance to begin on Jan. 1,” one said. “Why not wait until Nov. 1?”

Thursday, October 3, 2013 COLUMBIA DAILY TRIBUNE www.columbiatribune.com 7A

YESTERDAY: How does the health insurance marketplace work, and what coverage options do Missourians have?

TODAY: How many newly insured people will there be, and does Mid-Missouri have enough providers to meet demand?

COMING TOMORROW: The Missouri General Assembly con-tinues looking at Medicaid expan-sion. What are the prospects?

COMING SATURDAY: Even though the exchange for small businesses was delayed, business owners face tough choices.

☎ | WHOM TO CONTACT

Information from the federal government about Missouri’s Information from the federal government about Missouri’s marketplacemarketplace can be found at www.healthcare.gov or by can be found at www.healthcare.gov or by calling 800-318-2596. calling 800-318-2596. Primaris Health Business Solutions: Primaris Health Business Solutions: For individual coun-For individual coun-seling in Mid-Missouri, call 573-817-8300 or log on to seling in Mid-Missouri, call 573-817-8300 or log on to www.primaris.org/counseling. Program director: Jeremy www.primaris.org/counseling. Program director: Jeremy MilarskyMilarskyCentral Missouri Community Action’s health care/Obama-Central Missouri Community Action’s health care/Obama-care hotline:care hotline: 855-612-2259 855-612-2259Family Health Center of Boone County,Family Health Center of Boone County, 1001 W. Worley 1001 W. Worley St., Aaron Swaney, 877-677-4342St., Aaron Swaney, 877-677-4342Central Missouri Area Agency on Aging, Central Missouri Area Agency on Aging, 1121 Business 1121 Business Loop 70 E., Jean Leonatti, 800-369-5211, www.cmaaa.netLoop 70 E., Jean Leonatti, 800-369-5211, www.cmaaa.netAlso:Also: www.ma4web.org/health-insurance-marketplace- www.ma4web.org/health-insurance-marketplace-missouri/local-resourcesmissouri/local-resources

OES THAT MEAN?

Obamacare has many terms — some old, me old, some new — that are worth becoming familiar ming familiar with.Premium tax credits: An amount that can that can be subtracted from the amount of income f income tax a person or business owes. Premium tax emium tax credits will be off ered to some individuals and dividuals and small businesses that purchase health cover-ealth cover-age through Health Insurance Marketplaces rketplaces to help pay for the cost of coverage. You can ge. You can have the tax credit applied to your premium r premium over the course of the year or wait until you t until you fi le your taxes to claim the full amount.ount.Tax credits: Government health insurance surance subsidies for individuals will come in the form e in the form of tax credits. The money will be paid directly paid directly to the consumer’s health plan to help cover help cover

premiums. The subsidies are on a sliding scale premiums. The subsidies are on a sliding scale based on income. Each year, people will have based on income. Each year, people will have to “true up” with the Internal Revenue Ser-to “true up” with the Internal Revenue Ser-vice to make sure they got the right amount. vice to make sure they got the right amount. People who receive too generous a tax credit People who receive too generous a tax credit might owe money back to the government.might owe money back to the government.Tax penalty: Tax penalty: The fi ne levied on individuals The fi ne levied on individuals who disregard the individual insurance man-who disregard the individual insurance man-date. It starts small and gets bigger in subse-date. It starts small and gets bigger in subse-quent years. In 2014, it’s $95 or 1 percent of quent years. In 2014, it’s $95 or 1 percent of taxable income. By 2016, it’s $695 or 2.5 per-taxable income. By 2016, it’s $695 or 2.5 per-cent of taxable income, whichever is greater. cent of taxable income, whichever is greater. Thereafter, it’s adjusted for infl ation.Thereafter, it’s adjusted for infl ation.

Sources: Department of Health and Human Sources: Department of Health and Human Services, Blue Cross Blue Shield, The Associated Services, Blue Cross Blue Shield, The Associated Press, Kaiser Family Foundation, younginvin-Press, Kaiser Family Foundation, younginvin-cibles.orgcibles.org

LOOKING TO THE EAST | IMPLEMENTATION IN ILLINOIS

Awais Vaid, right, helps Mandy Wyatt sign up for health insurance Tuesday through the Aff ordable Care Act at the Champaign Urbana Public Health District in Champaign, Ill.

John Dixon/AP

Thousands visit Illinois exchange on the first day

CHICAGO (AP) — More than 71,000 people visited Illinois’ new health insurance market-place by late Tuesday, the first opportunity to comparison shop for coverage through a sys-tem that’s a key piece of Presi-dent Barack Obama’s signature health care law. But people hop-ing to enroll weren’t getting much further, as the federally run website experienced glitch-es and delays.

At a health center on Chicago’s west side, workers said their goal for the day was to get just one person enrolled, but none of the people who came in was able to do so. The same was true at the Champaign Urbana Public Health District office in Cham-paign.

Deborah Mitchell, 57, waited about an hour at Chicago’s West Side Health Authority before giv-ing up and making an appoint-ment for next week. Mitchell and her 62-year-old husband have insurance but wanted to see if she could get a better rate. She also wanted to try so she can report back to the congregation at the church where her husband is a pastor.

Mitchell took the delay in stride. “It’s the first day,” she said. “I’m looking for the whole week to be kind of jammed.”

Gyung Min Choi, 33, and his wife, 32-year-old Minyoun Ham, were trying to find coverage for her at the Champaign Urbana health district. She’s about five weeks pregnant, he said, and has no health care coverage, so she hasn’t yet seen a doctor.

“We want to get some cover-age for the baby’s” birth, said Choi, a materials science student at the University of Illinois from South Korea. He explained that their only other option would be private insurance, something he probably would struggle to afford on his $24,000-a-year income.

They hadn’t been able to enroll, though, after about a half-hour of trying.

Gov. Pat Quinn said the prob-lems with the website were understandable given the mag-nitude of the program. “We understand with any new pro-gram there will be glitches and bumps along the way,” he said at a news conference. “That’s what happens with any endeavor.”

The Chicago Democrat called it a “historic” day that will change the lives of hundreds of thou-sands of Illinois residents by helping them get health insur-ance. An estimated 1.8 million people in Illinois don’t have cov-erage; officials hope at least 300,000 of them will enroll through the marketplace by March 31.

Illinois residents wanting to shop for coverage start by visiting

a new website, Get Covered Illi-nois, where they can determine if they’re eligible for Medicaid or to buy insurance on the market-place.

Consumers who don’t qualify for Medicaid based on income are directed to the marketplace, where they also can find out if they’re eligible for federal tax subsidies. The site is run by the federal government because Illi-nois lawmakers did not vote to have the state create its own sys-tem. The state couldn’t say Tues-day how many people were able to enroll. But officials said about 2,200 people were directed to the Medicaid site and submitted applications.

Illinois also opened a call cen-ter where staff fielded questions from more than 350 callers Tues-day, which also marked the launch of a $33 million advertis-ing campaign to inform residents about Get Covered Illinois.

Still, officials were expecting a slow rollout. Although the law requires almost everyone to have health insurance, consumers have until the end of March to do so and avoid penalties for 2014. People who want their coverage to begin Jan. 1 must enroll by Dec. 15.

Patrick Lamanske and his wife, Ping Lamanske, 59, came to the Champaign Urbana Public Health District office to sign up for coverage for her. But after almost two hours of sitting in front of a laptop with a staff member, they hadn’t managed to get through the federal website. Patrick Lamanske, who is 66 and retired, said he has coverage through Medicare, but his wife does not.

“It’ll help me sleep better, knowing my wife’s got some kind of coverage,” the Champaign resident said as he waited at one of the half-dozen laptops set up in the office. She’s healthy, he said, but “you never know — you break a leg, you sprain an ankle.”

Julie Pryde, health district administrator, said she was “very frustrated” that people weren’t able to sign up. But she said peo-ple were being really patient.

Pryde said her office had been doing outreach to younger employees of small businesses, people with pre-existing condi-tions and others, including to a local halfway house where she found middle-age men who had never had access to health care other than when they were in prison.

Tuesday’s launch came the same day as shutdown of the federal government led by con-gressional Republicans who want to block the health care law. However, the shutdown had no immediate effect on the market-places.

Patrick Lamanske works Tuesday with Amanda Ziemnisky, right, to try to get health coverage for his wife, Ping, left, at the Champaign Urbana Public Health District offi ce.

David Mercer/AP

Kelly Camp, 51, was in the Boone County Family Health Center yesterday to receive treatment. While there, she got information about the new health insurance market-place. Camp, who recently was laid off , doesn’t qualify for Medicaid, and she makes too little to qualify for federal subsidies on the health insurance exchange.

Don Shrubshell/Tribune

The number of uninsured people in Boone County in 2012, according to the U.S. Census Bureau’s American Community Survey.

The number of uninsured people who will not qualify for premium subsidies (those below the poverty line)

12,431Uninsured people between 100 per-Uninsured people between 100 per-cent and 400 percent of poverty, cent and 400 percent of poverty, potentially qualifying for subsidies potentially qualifying for subsidies to purchase insurance on the ex-to purchase insurance on the ex-changechange

5,579Boone County residents earn less Boone County residents earn less than 138 percent of poverty and are than 138 percent of poverty and are uninsured. (These people would uninsured. (These people would have qualifi ed for Medicaid expan-have qualifi ed for Medicaid expan-sion, excluding most students who sion, excluding most students who likely still have coverage from their likely still have coverage from their parents)parents)

The total number of uninsured from sur-rounding Mid-Missouri counties, accord-ing to U.S. Census Small Area Health Insurance Estimates

alth consulting not-for-profi t that received a federal grant of $1 million to ketplace. The navigators who are already working in Columbia have had a

Ryan Henriksen/Tribune

than getting health insurance. Her biggest problem now is getting unemployment insur-ance to kick in while she looks for work.

Camp drove trucks for more than 10 years, and she has been unemployed before. She knows it sometimes takes a few weeks before unemployment checks start coming. She was laid off in 2008 when Dana Corp.’s Columbia factory cut more than 100 jobs as its customers — Detroit automakers — faltered that year. She struggled to find a job after that, even being told that she was overqualified when she applied at Watlow Electric’s local factory.

“They told me I’m overqualified even though I’ve been in a distribution warehouse for years,” she said.

Camp worked at 3M for a little more than a year, she said, but even then, she couldn’t afford the health insurance the company offered. She lived paycheck to paycheck, and she needs to find her next one quick.

“I don’t have four to six weeks to wait,” she said. “The rent man ain’t gonna wait. Boone Electric isn’t gonna wait. And neither is Ameren UE.”

subsidies