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HEALTH CARE REFORMY O U R G U I D E T O T H E A F F O R D A B L E C A R E A C T

NOVEMBER 10

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We strive to be a trusted community partner.Saint Joseph Regional Medical Center is here to provide you with the information you need about available health insurance plans. With locations to serve you in Mishawaka and Plymouth, our professionals can meet with you one-on-one to discuss your health insurance options.

Visit us at sjmed.com/aca or call 855.88.SJMED (855.887.5633) to schedule your appointment.

See the back page to

learn more aboutfree community

education sessions.

Key dates

Local impact

Local resources

Effects by household type

Small businesses

Expert advice

Health reform glossary

Enrolling safely

Step by step

10 key questions

Immigration

Essential benefits

Doctor shortage

Addiction treatment

Native American resources

Preventive care

Shopping for better deals

What do I do? — A flow chart

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HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 2

contents

Helping you understand health care changes

Since it became law more than three years ago, the Patient Protection and Affordable Care Act, commonly called the Affordable Care Act, has spurred a wide range of reaction, from glowing praise to harsh criticism.

More recently, reports of glitches and oversights have threatened to mar the law and its mission of ensuring that all Americans have affordable health care coverage. And there has been widespread confusion about the law, its programs, and enrollment, among other issues.

Today, the South Bend Tribune and Saint Joseph Regional Medical Center (SJRMC) are helping clear the confu-sion. We have partnered to produce a special section to help you understand the Affordable Care Act and what it means for you. We want to cut through the clutter.

This guide provides not only con-text and background, but also explains what you need to do, key deadlines, and where to go for help. The stakes are critical, as the Affordable Care Act af-fects millions of people.

SJRMC is working hard to reach out to the public, educate patients and con-sumers, and provide information that

not only eases confusion but also re-minds the public that patient protection is just as important as affordability. The Tribune, meanwhile, sees coverage of this law as part of its mission to provide the public with vital, relevant news.

The Affordable Care Act affects all segments of our community. And we know it is changing the face of health insurance in America, with an ocean of new and often confusing details.

We hope this section arms you with the information you need to navigate those waters.

contents Breast Cancer .................... 3Know what to expect after a diagnosis and learn more about a new single-stage reconstruction procedure.

Sports medicine ................ 4advanced diagnostics and treatment to improve your performance.

Joint Pain ........................... 5What could be wrong? common causes abound, but if the pain is severe, it could signal a serious problem.

New medical Staff ............. 7

Robotics Technology ........ 8introducing the next generation of orthopedics for knee and hip.

Cardiovascular ................ 10speed counts: our cardiology and neurology teams strive to improve outcomes for emergency patients.

Diabetes Care .................. 12you can turn things around if you are on the road to developing type 2 diabetes.

Digestive Health .............. 13an accurate diagnosis can help you manage digestive disorders.

Classes & Health Tips .... 14

Foundation News ............ 15

this free quarterly medical update is prepared by the Marketing department of saint joseph regional Medical center with the assistance of the Medical staff. please call 574-335-2351 with any questions or comments. inquiries or ideas can be addressed to medicalupdate@sjrmc.com.

Albert L. Gutierrez, president and ceoPamela Henderson, V.p. of MarketingMedical advisors: Physicians from SJRMC’s Integrated Leadership TeamsjrMc production team: Mai Nguyen, Christine Weist, and Lindahl Wiegand

The material provided in this magazine is intended to be used as general information only and should not replace the advice of your physician. Always consult your physician for individual care.

you may see members of our Michiana community pictured throughout this publication. they are featured for illustrative purposes only. We would like to thank all those who have participated in our sjrMc photo shoots. We are looking forward to capturing even more familiar faces!

STAY CONNECTED WITH SAINT JOSEPH REgIONAl mEDICAl CENTERwww.facebook .com/sjrmc

www.twitter .com/stjoemed

www.youtube.com/ sjrmcmarketing

www.sjmed .com

A Message to Our Readers

Welcome to the first issue of Michiana Medical Update, brought to you by the physicians

of saint joseph regional Medical center. this update will publish quarterly to offer you health and wellness information and keep you informed on the latest medical trends.

as you will read in this publication, we make significant investments in technol-ogy to ensure we are setting the standard for care in our community. on page 8, read about our new robotic-assisted joint replacement surgery. the procedure offers a new level of precision and world-class treatment for patients with arthritis of the knee or hip.

our system is also home to talented providers who strive to provide patients

“�We’re�called�on�to�care,�in�every�sense�of�the�word.”�

Albert gutierrez president and ceo

winter 2012

with peace of mind. confidence is never needed more than during an emergency. turn to page 10 to learn more about how our emergency code protocol is improving outcomes for heart attack and stroke patients and setting the gold standard for care.

We’re called on to care, in every sense of the word. this means an unwavering focus and commitment to all we serve. i hope you find the following pages and subse-quent publications a valuable resource for your health.

Albert GutierrezPresident and CEO Saint Joseph Regional Medical Center

The Best Ideas Come from You!Is there a particular health topic you’d like to read about in a future issue of Michiana�Medical�Update? Please email medicalupdate@sjrmc.com with “story idea” in the subject line.

Albert Gutierrez, President & CEO,Saint Joseph Regional Medical Center

Kim Wilson, President & Publisher, South Bend Tribune

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 3

Key dates in health care reform

March 23, 2010 — President Obama signs the Patient Protection and Affordable Care Act (ACA). The law requires most Americans to carry health insurance starting in 2014, and bars insur-ers from turning away the sick. It creates state markets for middle-class people without work-place coverage to buy private insurance, subsi-dized with tax credits. It expands Medicaid for the low-income uninsured.

March 29, 2010 — Health and Human Services Secretary Kathleen Sebelius and the health insurance industry reach a deal to fix the first glitch emerging from the complex legislation: vague language that compromised a guarantee that children with pre-existing medical conditions could get coverage right away.

Fall 2010 — During open enrollment, most health insurance plans begin offering coverage to young adults up to age 26 on a parent's policy. The popular early provision expanded coverage to more than 3 million people. Plans also begin covering preventive services at no charge.

Jan. 31, 2011 — Florida U.S. District Judge Roger Vinson rules that the ACA is unconstitu-tional. The lawsuit by 26 states would ultimately reach the Supreme Court.

June 21, 2011 — The Obama administration says it will look for fixes to another glitch, a twist that would have let several million middle-class people receiving Social Security payments get nearly free insurance meant for the poor. Enacted later, the fix saved an estimated $13 billion over 10 years.

Summer 2011 — Seniors hitting Medicare's prescription drug coverage gap start getting a 50 percent discount on brand name medications, part of the health care law's gradual closing of the "doughnut hole." In 2011, the typical senior in the gap saved about $600 on bills averaging $1,500.

Oct. 14, 2011 — Sebelius pulls the plug on the ACA's long-term care insurance program, because of doubts over its long-term financial solvency.

June 28, 2012 — With the unlikely support of conservative Chief Justice John Roberts, the Su-preme Court upholds the law's core requirement that most Americans carry health insurance, rul-ing the penalties to enforce it are a tax Congress is authorized to levy. But the court allows states to individually opt out of the Medicaid expansion, which accounts for about half the law's coverage expansion.

Summer 2012 — Employers and consumers receive more than $1 billion in rebates from their insurers, which are required under the ACA to spend at least 80 cents of every premium dollar on medical expenses and quality improvement, or refund the difference.

Jan. 1, 2013 — Tax increases to finance the ACA take effect on about 2.5 million households, individuals making more than $200,000 per year and couples over $250,000.

Winter/Spring, 2013 — States decide whether they'll run the new insurance markets and expand their Medicaid programs.

April 30, 2013 — Obama administration un-veils simplified forms consumers will use to apply for health insurance and financial assistance to pay their premiums. The first version was criti-cized as too complicated.

July 2, 2013 — In a surprise, the White House announces a one-year delay — until 2015 — of the law's requirement that companies with 50 or more workers must provide affordable coverage or pay fines. The administration says it's trying to iron out burdensome reporting requirements.

how we got here critical datesfor consumersOct. 1, 2013 — Online insurance markets open in every state. Consumers must sign up by Dec. 15 for coverage to take effect Jan. 1.

Jan. 1, 2014 — The law’s prohibitions against annual dollar limits on health care coverage and against denying coverage or providing it at inflated cost for women or people with pre-existing health conditions take effect.

The law also implements the second phase of the small business tax credit for qualified small businesses.

March 31, 2014 — Deadline for Americans to obtain health insurance or face tax penalties.

Jan. 1, 2015 — A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so those who provide higher value care will receive higher payments than those who provide lower quality care.

Associated Press

Thinkstock photo

By Kevin AllenSouth Bend Tribune

The number of St. Joseph County residents who don’t have health insurance could be cut in half as the Affordable Care Act takes full effect, a recent study found.

In reality, though, the number of uninsured likely won’t fall that far.

One reason is Indiana, like at least 22 other states, isn’t expanding Medicaid as part of the new health law.

The Kaiser Family Foundation, a nonprofit orga-nization that analyzes health care issues, estimates St. Joseph County has 37,000 uninsured residents younger than 65. The foundation focused on that age range because people 65 and older are eligible for Medicare.

The number of uninsured in the county, which has a total population of some 266,000 people, would decline to 18,000 if the state expanded Medicaid.

Dr. Thomas Felger, the health officer for St. Jo-seph County, said the choice by state officials has made it difficult to predict how many Hoosiers will gain health insurance under the new law.

When President Obama signed the Affordable Care Act into law in March 2010, it included an expansion of Medicaid to cover people with incomes up to 138 percent of the Federal Poverty Level. That’s $15,856 for a single person, for example, or $26,951 for a family of three.

Then the Supreme Court decided last year that the Medicaid expansion should be optional for states. The program is expanding in Michigan, but it’s not in Indiana.

Medicaid isn’t the only means for increasing the number of Americans who have health insurance, of course, but low-income Hoosiers could have a tough time finding coverage they can afford.

Online exchanges, where people can shop for insurance, opened Oct. 1. Although the rollout of the federal exchange at HealthCare.gov has been clunky, it is designed to give people an array of options and help them find coverage that works for them.

Hoosiers whose earnings are below the poverty level also may enroll in the Healthy Indiana Plan.

Gov. Mike Pence said during a visit to South

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 4

Many likely to remain uninsured

Clarence Walker, a bilingual outreach enrollment assistant with Indiana Health Centers, gives David Nelson some information about the Affordable Care Act last month outside the food pantry at Berean Seventh-Day Adventist Church in South Bend. SBT Photo/SANTIAGO FLORES

Law’s effect unpredictable; Indiana’s Medicaid decision a factor

nick Health Center at Chapin Street and Western Avenue, will continue to be available for people who remain “in the gaps” without insurance, Gutierrez said.

Diane Maas, vice president of managed care and business development at Beacon Health System, said the system, which operates Elkhart General Hospital and Memorial Hospital of South Bend, is expecting a slight increase in the number of insured people in the first year.

“I think we’ll see more volume next year as people understand the act and how to get on a plan,” she said.

Felger, the county’s health officer, said the health care law is not perfect by any means, but it should lead to improvements in the county’s overall health by making preventive care available to more people.

“We have so many uninsured people, it definitely affects the health of the county,” he said. “The preventive care will definitely be an improvement in that you’re getting more immunizations; you’re get-ting more screenings for cancer and other things.”

The Affordable Care Act requires individuals to obtain health insurance by March 31 or pay a fine, but there are exceptions for the poor. There also is a religious exemption for certain groups.

Uninsured residents in Michiana counties: • St. Joseph: 37,000 • Elkhart: 44,000 • LaPorte: 13,000 • Berrien: 21,000

Source: Kaiser Family Foundation

local uninsured

Bend on Oct. 1 — the day the online exchanges opened — that he would prefer expanding Healthy Indiana over expanding Medicaid.

“I think Medicaid as a system is broken and broke,” he said. “I think that imposing the cost of an expansion of Medicaid on Hoosiers in the long term ... is not in the health interests of our people and not in the fiscal interest of our state.”

Expanding Medicaid in Indiana would have covered an additional 430,000 people statewide, according to the Kaiser study. Healthy Indiana cov-ers fewer than 40,000.

Al Gutierrez, president and CEO of Saint Joseph Regional Medical Center in Mishawaka, said Health-Care.gov’s problems have complicated efforts to help people buy health insurance. He said some private insurers have added to the confusion by set-ting up websites that some people have mistakenly thought are the exchanges.

“We’re focused on enrolling as many people as we can and assisting people in navigating the process,” Gutierrez said.

Charity clinics, such as the Sister Maura Bran-

By Erin BlaskoSouth Bend Tribune

Cassandra Preston was unaware the federal Health Care Marketplace was about to open on Oct. 1, even though she was among millions of uninsured Americans required now to buy health insurance or pay a penalty.

And the 26-year-old Cass County, Mich., woman wasn’t alone.

According to a Kaiser Health poll, in the week leading up to the marketplace’s launch, 85 percent of the population, and 88 percent of the uninsured, were not aware it was about to open.

“My understanding is we’re going to have to pay a fee if we don’t have some kind of policy we’re going to work with, and it’s going to be $1,800,” said Preston, who, along with her 32-year-old husband Aaron, has been without health insurance for about two years now.

Next year, at least, the penalty is $95 per person or 1 percent of income, whichever is greater.

For the Prestons, whose combined household income, according to Cassandra, is less than $20,000, that adds up to a penalty of less than $200 next year if they decide not to buy insurance.

That Preston and others might not understand the Affordable Care Act down to the last detail is not surprising. It’s a complex law, for one. On top of that, it’s been the subject of numerous delay or repeal attempts — and one actual delay — over the past four years, adding to the confusion.

As recently as April, 40 percent of Americans were unaware the Affordable Care Act was even the law, with 7 percent believing it had been overturned by the Supreme Court and 12 percent believing it had been repealed by Congress, accord-ing to another Kaiser Health poll.

Knowing that to be the case, states, the federal government, local health care providers, not-for-profit groups, insurance agents and brokers and others have spent months preparing to educate people about the law, including the marketplace.

“It’s just very important that people know exactly what they’re signing up for,” said Maggie Scroope, a spokeswoman for Memorial Hospital of South Bend. “Because if you sign up for something that’s inap-propriate for you it could hurt you in the long run.”

Most Americans must have insurance by Jan. 1 or pay a penalty. The deadline to enroll without a

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 5

Beverly Rodio, health insurance services specialist, talks to Sondra Gardetto, manager for health information services, recently in the information station off the lobby of Saint Joseph Regional Medical Center in Mishawaka. SBT Photo/GREG SWIERCZ

Help offered to navigate marketplace

need help?• Visit healthcare.gov or call 800-318-2596

• Call Health Insurance Services at Saint Joseph Regional Medical Center (855-887-5633)

• Call the Health Professionals at Memorial Hospital of South Bend (574-647-6800)

• Call Lakeland HealthCare of St. Joseph, Mich. (269-556-7161)

• Contact a local insurance agent or broker registered with the Centers for Medicare and

Medicaid Services

Clearing confusion

penalty is March 31. To ensure coverage beginning Jan. 1, a person must enroll by Dec. 15.

The federal marketplace offers tax credits to people with a household income of between 100 percent and 400 percent of the federal poverty level, or between $23,550 and $94,200 for a family of four.

Memorial, for its part, is in the process of training about 30 “navigators” — experts trained and able to help navigate the marketplace.

In the coming weeks, the hospital plans to make those people available to the public at events throughout the community, Scroope said.

"So they’ll be going out to locations throughout the community — the library, we hope, and busi-nesses — and having time where people can come and walk through what’s the best option for them,” Scroope said.

Saint Joseph Regional Medical Center, mean-while, has an entire separate department, Health Insurance Services, dedicated to helping people navigate the wider health insurance marketplace, including the federal marketplace.

Sondra Gardetto, a licensed insurance benefits consultant, heads the department.

“We help people look at options inside and outside of the marketplace,” Gardetto said. “We’re going to help them assess what their options are and find out what the best plan is for them.”

Gardetto said 15,000 people are expected to enroll in the marketplace in north-central Indiana. Nationwide, the government expects as many as 7 million people to enroll by March 31.

So far, a variety of people have approached Saint Joseph about the marketplace, Gardetto said.

“We’ve had people come in who are early retirees ... we have people who have lost jobs, we have families coming in, we have people who are part time and have never had insurance,” she said. “We’ve seen all kinds of situations. We’ve even seen people with adult kids turning 26.”

In Michigan, St. Joseph-based Lakeland Health-Care is offering similar help to consumers and oth-ers. The health care provider has been designated a “Certified Application Counselor” organization by the federal government.

“Individuals in our community who need help in applying for and understanding the new health insurance options that are available are encouraged to contact Lakeland for information,” President and CEO Loren Hamel said in a statement. “We have trained staff ready to assist our neighbors, patients

and friends in getting the coverage they need.”As for Preston, the uninsured woman, she and her

husband are undecided about whether to buy insur-ance or pay the penalty. If they do buy insurance it will likely be on the open market.

“It’ll be more of a faith-based decision,” she said. “Like I said, we don’t have a very big income, but we’re well taken care of. We know God will take care of it.”

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Employers have a stake, too

Should you provide health insurance to your employees? Entrepreneurs have faced that question for years.

The Affordable Care Act will introduce a new program in 2014 designed to simplify the process of finding quality, reasonably priced health insurance for small business owners and their employees.

The Small Business Health Options Pro-gram (SHOP) is intended to provide more control over health spending, helping own-ers choose the level of coverage to offer and how much to contribute.

Business owners can still use insurance brokers to access SHOP but compare price and coverage side by side.The administration announced in July that businesses with 50 or more employees — those legally required to buy insurance for employees — will not be penalized in 2014 as originally planned.

Instead, penalties of $2,000 per employee for failing to provide insurance will be de-layed until 2015, giving businesses more time to prepare for the law’s reporting reuirements.

Tax BreaksThe government offers exclusive access to an expanded small business health-care tax credit, which covers as much as 50 percent of the employer contribution toward premiums.

Obtaining insurance through SHOP will also open the door to additional tax breaks, including the chance for enrollees and their employees to use pre-tax dollars to make premium payments.

Private CompaniesThe health insurance plans available in SHOP will be run by private health insurance companies, the same way small group plans are run now. All plans will offer the same benefits as a typical employer plan, including real protection against financial catastrophe.

Plans will present their cost and coverage information in a standard format, using plain language that’s clear and easy for business owners and employees to under-stand, according to HealthCare.gov.

By Kevin AllenSouth Bend Tribune

While the Affordable Care Act’s requirement for most Americans to obtain health insurance is taking ef-fect in 2014, businesses have another year to prepare before the law ap-plies to them.

There are still some factors, however, that businesses need to consider as their workers begin facing the individual mandate.

One simple measure that many companies are taking is posting notices to let employees know the health insurance exchanges opened Oct. 1.

Eileen Shue, vice president of corporate resources at Sterling Group in Mishawaka and past president emeritus of the Michiana chapter of the Society for Human Resources Management, said some businesses are also helping workers understand how much insurance costs on the exchanges and how much they’ll

have to pay in tax penalties if they decline affordable coverage from an employer.

Helping employees make good decisions, Shue said, can help them save money in the long run.

“From an employer’s perspective, educating our employees is key,” she said.

Tim Leman, president and CEO of Gibson, a regional insurance broker and risk management services firm in South Bend, said businesses might also want to prepare for some ad-ditional employees, or their spouses or dependents, to enroll in company health plans after the mandate takes effect.

“On a practical level, I think there’s going to be a heightened awareness among people in general who don’t have health insurance right now,” Le-man said. “I think from an employer perspective, what they might find is increased enrollment in their health plans.”

The Affordable Care Act’s indi-

vidual mandate requires people who don’t have health insurance to pay a penalty equal to 1 percent of their household income or $95 per adult in the household — whichever is higher. That provision is scheduled to take effect in 2014, and the online ex-changes that opened Oct. 1 are sup-posed to help people without insur-ance find policies they can afford.

The law’s requirement for every company with the equivalent of 50 or more full-time employees to offer health insurance to those who work at least 30 hours per week is sched-uled to take effect in 2015. Employers that don’t fulfill that requirement will face a $2,000 fine for each full-time worker, excluding the first 30.

The employer mandate was scheduled to kick in next year, but the Obama administration announced in July that it was delaying it until 2015 after executives and business owners nationwide complained about confu-sion surrounding the rule’s complex-ity and unclear directions.

Thinkstock photo

small business impact

Firms help employees understand individual mandate

By Kevin AllenSouth Bend Tribune

Buying health insurance can be a daunting task, especially with new op-tions available under the Affordable Care Act.

It’s Sondra Gardetto’s job to help people on that front.

Gardetto, a licensed insurance ben-efits consultant, is in charge of Health Insurance Services for Saint Joseph Regional Medical Center in Mishawaka. She was previously deputy director for Covering Kids & Families of Indiana. At Saint Joseph, she is dedicated to help-ing people navigate the health insur-ance marketplace.

“We want to make sure people know what their choices are, know how the insurance works,” she said, “and what’s really important is if they are already seeing a primary care physician or they have a particular hospital that they’d like to go to, we want to make sure whatever plan they choose, that physi-cian or hospital is considered in network for them.”

The Tribune sat down with Gardetto recently to talk about what people can expect if they’re seeking coverage un-der the new health care law.

How should I get started?The first thing to do is go to the

HealthCare.gov website and apply on-line.

Even before you apply, you can look to see what plans and prices are in your area to kind of get an idea of the insur-ance options and the cost.

The first step, if they want to go through the marketplace, is to create an account.

You select your state, and you can apply online or apply by phone. The first part of this is creating the account and verifying your identity.

Then it goes through a series of questions that will help them determine if you are eligible for a tax credit.

That process, depending on your family size and the number of people who are in need of coverage, it takes

maybe 30 to 45 minutes.Learn more about the enrollment process on pages 10-11.

If I needed help, who could help me?

If you need assistance while you’re doing this, you can actually have as-sistance from somebody who’s gone through the training called a navigator or a certified marketplace broker — that’s what I am.

There’s a phone number they can call. It’s 1-800-318-2596. ... There is also a paper application they can fill out and mail in.

What kind of choices are available?

In the state of Indiana, for example,

in St. Joseph County, there are four insurance companies that are approved to participate in the marketplace. In one of the other counties, they would have different plans, because they want to make sure they’re offering plans that are in network for that region.

It’s important to note which county you live in (on HealthCare.gov), so you’re seeing the appropriate plans.

They all must offer 10 essential health benefits. ... That includes doctor visits, prescription drugs, hospitaliza-tion, immunizations and many other things.

Most people who apply will qualify for a lower cost (because of tax cred-its).Learn more about essential health benefits on page 15.

How much do the plans cost?The plans are put into five catego-

ries, from catastrophic to platinum. With insurance in general, the higher the amount of your deductible — the amount you’re willing to pay out of your pocket — lowers your premium.

If you chose what they call a bronze plan, where the plan pays 60 percent and you’re paying 40 percent (of your medical costs), that’s going to be a little bit cheaper than if you go with a gold plan, in which 80 percent of your cost is covered by insurance and you’re paying 20 percent.

The higher the deductible, the lower your premium, but you have to know how you’re going to meet that deduct-ible if you get sick or injured.

Some plans may offer coverage for dental, some may offer a vision plan, so that’s going to affect your pricing.

What determines if a person can get coverage through Medicaid. That's not changing in Indiana, right?

That’s not changing. That’s all based on income. Those eligibility guidelines are still in place.

Going through the healthcare.gov website will tell somebody if it looks like they might be eligible for enroll-ing in Medicaid or, for us, the Healthy Indiana Plan.

How many people are expect-ed to get insurance through the exchange in St. Joseph County?

The last I had heard they were estimating about 13,000 to 15,000 individuals that could potentially enroll through the marketplace.

It’s important for folks to know that if they want their coverage to be effec-tive as of Jan. 1, they need to enroll in a plan by Dec. 15. If they wait until after Dec. 15, and say it’s Dec. 20 when they enroll in a plan, their coverage will begin Feb. 1.

They do have until March 31 to enroll in a plan.

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 8

Sondra Gardetto, a manager at Saint Joseph Regional Medical Center’s Health Insurance Services department, shows the sign-up process for the HealthCare.gov website, part of the Affordable Care Act insurance exchange. SBT Photo/JAMES BROSHER

Expert helps people find their way

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 9

© FOTOLIA / AP

A new vocabularyThe Patient Protection and Affordable Care Act has spawned its own jargon. With the law finally about to take full effect, consumers might want to get familiar with some of the terms:

Affordable Care Act — The most common formal name for the health care law. Its full title is the Patient Protection and Affordable Care Act, or PPACA. Opponents still deride the law as “Obam-acare,” but Obama has embraced that term, saying it shows he cares.

Employer mandate — A federal require-ment that companies with 50 or more workers pay a penalty to the government if one of their workers obtains taxpayer subsidized coverage through the law. Effective Jan. 1, 2015. Intended to keep companies from “dumping” employees into public coverage.

Individual mandate — A federal require-ment that virtually everyone in the United State has health insurance, either through an employer, a government program or by buying his own plan. Effective Jan. 1, 2014. Exemptions for financial hardship and religious objections. Does not apply to illegal immigrants. People who ignore the man-date will face fines from Internal Revenue Service.

Essential health benefits — Basic health benefits most health insurance plans will have to cover starting in 2014. They include office visits, emergency services, hospitalization, rehab care, mental health and substance abuse treatment, prescriptions, lab tests, prevention, maternal and newborn care, and pediatric care.

Exchanges — Online health insurance marketplaces in each state where consumers can get private health insurance, subsidized by the government. Open enrollment started Oct. 1, and the coverage takes effect Jan. 1. Exchanges can be run by the states, the federal government, or a state-federal partnership. Small businesses will have access to their own exchanges.

Medicaid expansion — The health care law also expands the federal-state safety-net pro-gram to cover more low-income people. Medicaid is expected to account for close to half of the 30 million uninsured people who, the Congressio-nal Budget Office estimates, eventually will gain coverage through the law. The federal government will pay the full cost of the new coverage from 2014-2016, then phase down to 90 percent. States are free to reject the expansion. In those states, which include Indiana, many adults below the poverty level would remain uninsured.

Metal levels — The four levels of coverage available through exchange plans, called bronze, silver, gold, and platinum. Bronze plans feature the lowest monthly premiums, but cover only 60 per-cent of average costs. Platinum plans cover 90 percent of expected costs.

Pre-existing condition — An ongoing or past health problem. Currently insurers can use pre-existing conditions to deny or restrict coverage, or charge more. Those practices will be barred by federal law starting Jan. 1, and insurers will have to accept all applicants.

Tax credits — Government health insurance subsidies for individuals will come as tax credits. The money will be paid directly to the consumer's health plan. Subsidies are based on income. Each year, people will have to "true up" with the IRS to make sure they got the right amount. People who receive too generous a tax credit may owe money back to the government.

Tax penalty — The fine levied on individuals who disregard the individual insurance mandate. It starts small and gets bigger in subsequent years. In 2014, it’s $95 or 1 percent of taxable income. By 2016, it's $695 or 2.5 percent of taxable income, whichever is greater. Thereafter it’s adjusted for inflation.

sliding scaleSavings depend on income and family size. The amount you save depends on your family size and how much money your family earns.

In general, if your income falls within the following ranges, you’ll qualify to save money on your premiums in 2014. The lower your income within these ranges, the more you’ll save. (The amounts be-low are based on 2013 numbers and are likely to be slightly higher in 2014.)

If your income falls below the amounts shown, you may qualify for coverage under your state’s Medicaid program. But if your state is not expanding Medicaid in 2014 (Indiana is not) and you don’t qualify under your state’s rules, you can’t get lower costs on Marketplace coverage based on your income.

$11,490 to $45,960 for individuals$15,510 to $62,040 for family of 2$19,530 to $78,120 for family of 3$23,550 to $94,200 for family of 4$27,570 to $110,280 for family of 5$31,590 to $126,360 for family of 6$35,610 to $142,440 for family of 7$39,630 to $158,520 for family of 8

The penalty in 2014 and beyondThe penalty in 2014 is calculated one of two ways. You’ll pay whichever of these amounts is higher:• 1% of your yearly household incomeThe maximum penalty is the national average yearly premium for a bronze plan.• $95 per person for the year $47.50 per child under 18. The maximum penalty per family using this method is $285.

The fee increases every year. In 2015, it’s 2% of income or $325 per person. In 2016, and later years, it’s 2.5% of income or $695 per person. After that, it is adjusted for inflation.

Associated PressWashington

Getting covered might take you more than one sitting. In a media preview, it felt like a cross between doing your taxes and making an important pur-chase that requires research.

"Nothing like this has ever existed be-fore," said Health and Human Services Secretary Kathleen Sebelius.

You'll need accurate income infor-mation for your household, plus some understanding of how health insurance works.

The process involves federal agen-cies electronically verifying your identity, citizenship and income, and you have to sign that you are providing truthful information, subject to perjury laws.

You heard it was going to be like buy-ing airline tickets online? Not quite. But it's not the government poking into your medical records.

People who don't have health care on the job can apply online, via a call center, in person or by mail. Foreign lan-guage interpreters are available through the call centers.

The main steps are:l Identify yourself and your family.l Provide current information on income, jobs and any available health insurance options.l Learn how much financial assistance you're entitled to.l Shop for a health plan and enroll.

Many people will qualify for tax credits to help buy a private insurance plan. The government will send money directly to your insurer, and you'll make arrangements to pay any remaining premium.

The poor and near-poor will be steered to Medicaid in states that agree to expand that program. Indiana has not.

Here's an overview of what to expect:l Go to healthcare.gov and click on "Get Insurance." The site has links to every state market. Set up an account and password. Provide your contact informa-

tion and the best way to reach you.l Tip — Treat your password like a bank account or credit card password.l Now you can tackle the actual appli-cation. You'll need birth dates and Social Security numbers for yourself and fam-ily members on your federal tax return.l You'll also be asked if you're a citizen. Legal immigrants will need their immi-gration documents.l Tip — You don't have to finish the entire application at once. You can save your work and come back later.l You may need your most recent tax return, pay stubs and details on other income, such as alimony, pensions and rents. You can still apply if you haven't filed a tax return. You'll also be asked about access to health insurance through your job. You may be required to take that insurance if available.

Your personal and income details will be routed through a new govern-ment entity called the data services hub, which will ping agencies like Social Security, Homeland Security and the Internal Revenue Service for verification. The feds will also rely on a major private credit reporting company to verify in-come and employment.

How smoothly all this works is one of the big unknowns. It could get tedious if discrepancies take time to resolve.

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 10

What does it take to enroll? Beware misleading insurance websitesBy Emery P. DalesioAssociated Press

Insurance regula-tors and an industry trade group warn that this fall’s rollout of the health insurance mar-ketplaces created by federal law opened the door for bad actors at the same time that it gives brokers and agents a business opportunity. New Hampshire’s insurance commissioner sent a cease-and-desist letter to an Arizona company he accused of building a website that could mislead health care coverage shoppers into thinking it was the official New Hampshire marketplace. The site was taken down. Regulators in Wash-ington state and Penn-sylvania also have told private agents to change websites that seemed likely to convince con-sumers they were con-necting to government-run sites. Connecticut’s insur-ance department warned agents and brokers this summer that it will take action against agents who mislead consum-ers or design sites to replicate the state-run exchange.

AP Photo/J. DAVID AKE

l Tip — Provide an accurate estimate of your expected income for 2014. Lowball it, and see a smaller tax refund in 2015. Overestimate it, and you won’t get as big a tax credit now.

With your tax credit, you can finally shop for insurance. Be aware that you’ll probably have to live with your decision until the next annual enrollment period.

You’ll have up to four levels of cover-age to consider: bronze, silver, gold and platinum. Plans at every “metal level” cover the same benefits and have a cap of $6,350 a year in out-of-pocket expenses for an individual, $12,700 for families.

Bronze plans have lower premiums, but cover about 60 percent of medical costs. Policyholders will pay the difference, up to the annual out of pocket cap. Platinum plans have the highest premiums, but cover 90 percent of costs. Young adults up to age 30 can pick a skinny “catastrophic” plan — but you can’t use your tax credit on a catastrophic plan.l Tip — Make sure your doctors and hospitals are in the plan you pick. l Tip — Your share of the premium could be lower — even zero — if you ap-ply your tax credit to a bronze plan. l Tip — Check if you are also eligible for “cost-sharing subsidies.” Extra help with out-of-pocket costs is available to people with modest incomes. But only with a silver plan.

The correct website is www.healthcare.gov

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 11

HEALTH CARE REFORM

QWhen do I have to decide whether to buy health insurance and what hap-

pens if I don't?

ABeginning in 2014, virtually all Americans will be required to have health insurance or pay an

annual penalty to the government. For an individual, the fine begins at a minimum of $95 in 2014, step-ping up annually to a minimum of $695 by 2016. The fine for uninsured children in 2014 is $47.50 for each child, although the maximum a family would have to pay in penalties next year is $285. Those fees climb each year.Federal researchers predict that about 6 million people could be hit with fines by 2016.Those who owe penalties would see their tax refunds docked. Not everyone who fails to buy insurance will be forced to pay up — those ex-empted from the requirement to have insurance, such as prison inmates, would not be penalized, for example. That also would be the case with people who earn so little that they are not required to file a tax return.People owing the government a fine under the law

could try to massage their tax returns to avoid receiving a refund, and thus the government would have nothing to claim. It's also possible people could try to exploit the religious exemption, for example, to avoid buying insurance and getting hit with a penalty.According to the government, the IRS plans to hold back the amount of the penalty fee from future tax refunds, but there are no liens or criminal penalties for failing to pay.

QWhat are health insurance exchang-es and how do they work?

AExchanges are the online markets on which individuals and small businesses will buy

private health insurance. Think of them as one-stop-shopping destinations similar to Amazon.com that are supposed to give consumers a quick way to compare insurance policies. But they might not be available to some consumers until later. That could leave many who lack job-based coverage to enroll by mail or through call centers. Still, consumers are expected to be able to see all their options in the exchanges and choose their health plans based

on price, benefits and other features. Many partici-pants will qualify for federal subsidies in the form of tax credits to help ease the cost. The amount is based on income and is available to individuals making up to $45,960, or $94,200 for a family of four. Shoppers will have different buying experi-ences depending on who is running their exchanges — the state, federal government or a combination of the two. Enrollment began Oct. 1, with health care coverage starting Jan. 1.

QHow will actual health care coverage and services be different

under the new law?

ACoverage in the exchanges will be more comprehensive than what is typically avail-

able to individuals in the current health insurance market, which is dominated by bare-bones plans. It will resemble what a successful small business offers its employees. All plans in the exchange, and most outside it, will have to cover a standard set of benefits, including hospitalization, doctor visits, prescriptions, emergency room treatment, and

Associated Press

Q APolls show many Americans remain mystified by the Patient Protection and Affordable

Care Act, or "Obamacare" as it is commonly known. But there's an obvious starting point: Do you have health care coverage?

If your employer provides health insurance for you, it's likely you don't have to do anything on Oct. 1, when enrollment begins. The president has said you will be able to keep your doctor and your plan.

For others — those without insurance — it's more complicated. The law requires virtually all U.S. citizens and legal residents to have coverage or pay a penalty.

That will happen either through an expanded government Medicaid program, which would cover costs for lower-income people, or by requiring people without coverage

to buy it. Financial help will be available for those who qualify, based on income.To enroll through Medicaid, an individual would have to have an income that tops out $15,400, or about $31,000 for a family of four.

There are just a few exceptions to the requirement for coverage, including for prison inmates, people who entered the country illegally, those facing financial hardship and religious objectors.

10 key questions consumersHEALTH CARE

How do I know whether the new health care law applies to me?

South Bend TRIBUNE | November 10, 2013 | 12 - 13

should knowOVERHAUL:maternal and newborn care. Under the law, insur-ers can't turn away people or charge them more because of health problems or chronic illnesses. In-surers also are banned from setting different rates based on gender. Middle-aged and older adults can't be charged more than three times what young people pay, but insurers can impose penalties on smokers. Most health insurance plans have to cover certain preventive services. Those include routine vaccinations, vision and hearing tests for children, and screenings for diabetes, high cholesterol, colon cancer and high blood pressure.

QI currently have insurance through my employer. Will anything change?

AFor many people who have health insurance through their employer, the Kaiser Family

Foundation says not a lot is expected to happen right away. Some workers may receive a financial break from the new cap on out-of-pocket expenses and free preventive care. But some larger compa-nies, those with 50 or more employees, already are looking for ways to cut costs and avoid getting hit with a new tax set to take effect in 2018 on so-called "Cadillac" insurance plans. Those are defined as plans valued at $10,200 or more for individual coverage and $27,500 for family policies. United Parcel Service, for example, informed its white col-lar employees that it will no longer cover spouses if they can get coverage through their own employ-ers. Delta Air Lines, meanwhile, recently predicted its workers may have to help shoulder the cost of various new mandates under the Affordable Care Act, such as coverage for employees' children until they are 26 years old and coverage for workers who had previously opted out but will now be required to have health insurance.

QThe government has delayed the large-business mandate for a year,

but what will the law mean for owners of smaller businesses?

AUnder the Affordable Care Act, a small busi-ness is defined as having anywhere from two

to 50 employees. Those firms are not required

to provide their workers with health insurance. But businesses with employment levels close to the 50-employee threshold have until 2015 to calculate whether it's worth reducing their work-force or cutting workers' hours to avoid a series of escalating penalties that kick in if just one of their employees ends up receiving government-subsidized health care. Meanwhile, many smaller businesses appear to be taking a wait-and-see approach before determining whether to buy coverage through health insurance marketplaces geared toward their needs. In some states, they won't be able to compare rates with their current insurance plans until open enrollment begins in October. The business-to-business outreach man-ager at Connecticut's health insurance exchange, for example, predicts the plans will ultimately be attractive to smaller businesses that did not always offer insurance coverage.

QWill I be forced to change doctors or health plans even if I don't want to,

and will my choices for both be limited?

AYou can maintain your current providers if you have job-based insurance and can

choose any available primary care provider in your insurance plan's network. However, the influx of patients who will be newly insured under the Affordable Care Act could overwhelm the health care system in some areas. That could mean you will see a physician assistant or nurse practitioner, rather than an actual physician.In general, the Obama administration says the law offers new rights and protections whether you have coverage or need it, but there are some exceptions. The new rights do not apply to health plans created or bought before March 23, 2010.

QIf I currently buy my own insurance, can I keep it or do I have to change?

AIf you have individual insurance — a plan you bought yourself rather than what you

get through an employer — you should be able to change to a new plan if you choose. It also will be illegal for insurance companies to cancel

your coverage if you make simple mistakes on forms, but you still can be canceled for intentionally making false claims. If you have COBRA continuation health coverage, you can maintain it or decide to buy a new insurance plan. If you select a plan by Dec. 15, you can have coverage starting Jan. 1.

QI’ve heard of bronze, silver, gold and platinum. What does that mean?

ABronze, silver, gold and platinum refer to the types of insurance policies available to business-

es and individuals under the exchanges created by the health care law. The categories reflect how much premiums will cost each month and the amount you will pay for such things as hospital visits and prescrip-tion medications. The percentage covered by the plan increases from bonze to platinum. The lowest-cost plan is bronze, in which the insurance company covers 60 percent of the expenses and the individual will pay 40 percent. The highest-cost tier is platinum, in which the insurer covers 90 percent of the expenses and the individual pays 10 percent.

QIs subsidized care available for immigrants?

AIt depends on whether they are in the country legally. Legal immigrants will be required to buy

health insurance or pay a tax penalty if they don't. They can buy insurance through the health care exchanges and are eligible for the subsidies. Most legal immigrants cannot enroll in Medicaid if they have been in the U.S. for less than five years, although states have the option to waive the waiting period for pregnant women and children. Some legal immi-grants will not be eligible for Medicaid, regardless of the amount of time they have been in the country.Immigrants who are in the country illegally will not be eligible to buy insurance through the exchanges. They also are ineligible for Medicaid, although they remain eligible for emergency care under the law. Young immigrants who had been granted "deferred action" status by the Obama administration to avoid deporta-tion by obtaining temporary work permits also will not be eligible for the exchanges or Medicaid.

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 14

Teresa Barta, flanked by her 5-year-old daughter Rosa and 6-year-old son Pablo, listens to the national anthem at the start of her naturalization ceremony in a classroom where she teaches Spanish in Lincoln, Neb., in October. The Obama administration is stressing that information submitted while signing up for coverage under the new health care law will not be used to enforce immigration law. AP Photo/The Lincoln Journal-Star, Eric Gregory

Feds say personal info used only for health careImmigration action not aimed at insurance seekersBy Darlene SupervilleAssociated Press

WASHINGTONThe Obama administration is stressing that information sub-

mitted while signing up for coverage under the new health care law will not be used to enforce immigration law.

That’s always been the practice, but fear among some legal immigrants that personal details could be used against them led the U.S. Immigration and Customs Enforcement agency to clarify. The agency reiterated it does not use information provid-ed during enrollment to pursue civil immigration enforcement.

People living illegally in the U.S. are barred from benefits un-der the Affordable Care Act, but U.S. citizens and legal residents living with them may be eligible.

Some applicants must provide information on citizenship sta-tus of those who live with them to help make sure the household is processed correctly.

ICE “does not use information about such individuals or members of their household obtained for purposes of determin-ing eligibility for such coverage as the basis for pursuing a civil immigration enforcement action against individuals or members of their household,” the memo said.

Spokeswoman Gillian Christensen said that statement is consistent with the agency's long-standing practices.

The agency “is focused on sensible, effective immigration enforcement that prioritizes the removal of criminal aliens and egregious immigration law violators,” Christensen said.

Immigrant advocates welcomed the administration's decision to be clear about how a person's information will be used.

Jennifer Ng'andu, a health policy expert with the National Council of La Raza, a Latino advocacy group, said advocates want uninsured Hispanics to not be afraid to sign up for cover-age.

“For us, it’s an imperative to make sure the community is in-formed about this because we want people to be reassured they can look at their options without fear, figure out if they’re eligible and pursue the enrollment process,” Ng'andu said.

Read the memo online:Immigration and Customs Enforcement memo: www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdf

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 15

Key changes to health care servicesAssociated Press

An overview of some of the key changes to health care services under the Affordable Care Act

Essential health benefitsUnder the law, health insurers must cover 10

essential benefits. This will make health plans more costly, but also more comprehensive. Start-ing next year, the rules will apply to all plans offered to individuals or through the small-group market to employers with 50 or fewer workers. The essential-benefits requirement does not apply to plans offered by larger employers, which typi-cally offer most of these already.

The covered benefits are: ambulatory patient services; emergency services; hospitalization; ma-ternity and newborn care; mental health and sub-stance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; man-agement of chronic diseases, and preventive and wellness services; and pediatric services, including dental and vision care.

People will be able to pick from insurance plans with differing levels of coverage and varying costs for co-pays and premiums. But insurers will have to cover a certain percentage of the services' cost.

"Most of the important services people need are covered, though there may be a slight variation (from state to state)," says Jennifer Tolbert, direc-tor of state health reform for the Kaiser Family Foundation.

Dental and visionNeed a teeth-cleaning or eye exam? You still

could be reaching into your own wallet to cover the cost even after the Affordable Care Act takes full effect next year. Dental and vision care is consid-ered an essential benefit for children aged 18 and younger whose parents or guardians get insurance through the individual or small-group plans. The law does not mandate this coverage for adults, but some states could choose to have them covered.

Still, getting dental coverage for children and teenagers might be a bit complicated depending on where you live. States can choose to offer those items as stand-alone plans, and federal subsidies would not help pay for the costs.

Pre-existing conditionsThis is a major change under the law. Starting

in 2014, most plans — whether obtained through an employer or on the marketplace — cannot deny coverage or charge more money because of a pre-existing health conditions.

However, if you have what is known as a grand-fathered individual plan — a plan you buy yourself that was in existence before March 23, 2010, and has remained unchanged — then this rule would not apply. So check the details on your plan and consider shopping around.

Out-of-pocket spending/Lifetime limitsUnder the law, the amount of money people will

have to pay out-of-pocket each year for medical and prescription drug costs will be capped at $6,350 for individuals and $12,700 for a family. These limits are separate from the monthly premiums people pay. The limits take effect in 2014 for those buying insurance on the state health insurance exchanges. For those with employer-based coverage, the re-strictions will be fully in place in 2015.

In addition, most insurance plans will be prohib-ited from setting lifetime cost limits on coverage for essential health benefits. This means your insurer cannot deny you coverage because your medical bills have gone over a certain amount.

Age 26One popular provision of the health care law

already is part of most insurance plans — allowing young people to stay on their parents' insurance plans until age 26. This also covers dependents, including step-children, adopted children and some foster children. This benefit will be required of all plans that provide dependent care. Starting in 2014, younger people can remain on a parent's or caregiver's plan even if they have an employer op-tion of their own.

0

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4,000

6,000

8,000

$10,000

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0

2,000

4,000

6,000

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$10,000

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How much Americans spend on health care

Where Americans get their health insurance

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 16

Family doc shortage could growMedical resident Stephanie Place examines Maria Cazho at the Erie Family Health Center in Chicago. A shortage of primary care physicians in some parts of the country is expected to worsen as millions of newly insured Americans gain coverage under the federal health care law next year. AP File Photo/M. Spencer Green

Associated PressColumbus, Ohio

Getting face time with the fam-ily doctor could soon become even harder.

A shortage of primary care physi-cians in some parts of the country is expected to worsen as millions of newly insured Americans gain cover-age under the federal health care law next year. Doctors could face a back-log, and patients could find it difficult to get quick appointments.

Attempts to address the provider gap have taken on increased urgency ahead of the law's full implementa-tion Jan. 1, but many of the poten-tial solutions face a backlash from influential groups or will take years to bear fruit.

Lobbying groups representing doctors have questioned the safety of some of the proposed changes, argued they would encourage less collaboration among health profes-sionals and suggested they could create a two-tiered health system offering unequal treatment.

Bills seeking to expand the scope of practice of dentists, dental thera-pists, optometrists, psychologists, nurse practitioners and others have been killed or watered down in numerous states. Other states have proposed expanding student loan reimbursements, but money for doing so is tight.

As fixes remain elusive, the shortfall of primary care physicians is expected to grow.

Nearly one in five Americans already lives in a region designated as having a shortage of primary care physicians, and the number of doctors entering the field isn't expected keep pace with demand. About a quarter million primary care doctors work in America now, and the Association of American Medical Colleges proj-ects the shortage will reach almost 30,000 in two years and will grow to about 66,000 in little more than a decade. In some cases, nurses and physician assistants help fill in the gap.

The national shortfall can be at-tributed to a number of factors: The population has both aged and become more chronically ill, while doctors and

“If you don’t have a primary care provider,

you should find one soon.” Dr. Andrew Morris-Singer,President and co-founder of

Primary Care Progress

Continued on next page

clinicians have migrated to specialty fields such as dermatology or cardiol-ogy for higher pay and better hours.

The shortage is especially acute in impoverished inner cities and rural areas, where it already takes many months, years in some cases, to hire doctors, health professionals say.

"I'm thinking about putting our hu-man resources manager on the street in one of those costumes with a 'We will hire you' sign," said Doni Miller, chief executive of the Neighborhood Health Association in Toledo, Ohio. One of her clinics has had a physician opening for two years.

The problem will become more acute nationally when about 30 million uninsured people eventually gain cov-erage under the Affordable Care Act, which takes full effect next year.

Roughly half of those who will gain coverage under the Affordable Care Act are expected to go into Medicaid, the federal-state program for the poor and disabled. States can opt to expand Medicaid. Michigan has. Indiana hasn’t.

Mark Bridenbaugh runs rural health centers in six southeastern Ohio counties, including the only primary care provider in Vinton County. The six counties could see some of the state's largest enrollments of new Medicaid patients per capita under the expan-sion.

As he plans for potential vacancies and an influx of patients, Bridenbaugh tries to identify potential hires when they start their residencies — several years before they can work for him.

"It's not like we have people falling out of the sky, waiting to come work for us," he said.

Some states are experimenting with ways to fill the gap.

Texas has approved two public medical schools in the last three years to increase the supply of family doc-tors and other needed physicians. New York is devoting millions of dollars to programs aimed at putting more doctors in underserved areas. Florida allowed optometrists to prescribe oral medications — including pills — to treat eye diseases.

The federal health care law at-

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 17

Medical resident Stephanie Place examines 2-month-old Abigale Lopez at the Erie Family Health Center in Chicago in March. As clinics gear up for the expansion of health insurance, they’re recruiting young doctors. AP File Photo/M. Spencer Green

tempts to address the anticipated shortage by including incentives to bolster the primary care workforce and boost training opportunities for physicians' assistants and nurse practitioners. It offers financial assistance to support doctors in underserved areas and increases the level of Medicaid reimbursements for those practicing primary care.

Providers are recruiting young doctors as they gear up for the ex-pansion.

Stephanie Place, 28, a primary care resident at Northwestern Uni-versity's medical school in Chicago, received hundreds of emails and phone calls from recruiters and health clinics before she accepted a job this spring.

The heavy recruitment meant she had no trouble fulfilling her dream of staying in Chicago and working in an underserved area with a largely His-panic population. She'll also be able to pay off $160,000 in student loans

through a federal program aimed at encouraging doctors to work in areas with physician shortages.

Place said the federal law turned needed attention to primary care as a specialty among medical students.

"Medical students see it as a vi-brant, evolving, critical area of health care," she said.

Even so, many experts say the gap between doctors and those gain-

ing care under the health reforms in many parts of the country will not close quickly. Access to care could get worse for some people before it gets better, said Dr. Andrew Morris-Singer, president and co-founder of Primary Care Progress, a nonprofit in Cambridge, Mass.

"If you don't have a primary care provider," he said, "you should find one soon."

Primary care doctors state by stateA look at active primary care physicians by state, according to a 2011 report by the Association of American Medical Colleges. The doctors rep-resent those who self-reported dealing directly with patients, as opposed to primary care physicians who are teaching, involved in research or doing mostly administrative work.

State Population # of docs Rate/100K RankIndiana 6.5 mill. 4,588 71.2 36Michigan 9.9 mill. 8,487 85.5 18USA 309 mill. 245,000 79.4 na

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 18

It has been six decades since doc-tors concluded that addiction was a disease that could be treated, but today the condition still dwells on the fringes of the medical community. Only 1 cent of every health care dollar in the United States goes toward ad-diction, and few alcoholics and drug addicts receive treatment. One huge barrier, according to many experts, has been a lack of health insurance.

But that barrier crumbles in less than a year. In a major break with the past, 4 million people with drug and alcohol problems — from homeless drug addicts to working moms who drink too much — suddenly will be-come eligible for insurance coverage under the new health care overhaul.

The number of people seeking treatment could double over cur-rent levels, depending on how many states decide to expand their Medic-aid programs and how many addicts choose to take advantage of the new opportunity, according to an Associ-ated Press analysis of government data. The analysis compared federal data on the addiction rates in the 50 states, the capacity of treatment programs and the provisions of the new health law.

The surge in patients is expected to push a marginal part of the health

care system out of church basements and into the mainstream of medical care. Already, the prospect of more paying patients has prompted private equity firms to increase their invest-ments in addiction treatment compa-nies, according to a market research firm. And families fighting the afflic-tion are beginning to consider a new avenue for help.

"There is no illness currently being treated that will be more af-fected by the Af-fordable Care Act than addiction," said Tom McLel-lan, CEO of the nonprofit Treat-ment Research Institute and President Barack Obama's former deputy drug czar. "That's because we have a system of treatment that was built for a time when they didn’t understand that ad-diction was an illness."

Not enough bedsBut those eager for a new chance at

sobriety may be surprised by the reality behind the promise. The sys-tem for treating substance abuse — now largely publicly funded and run by counselors with limited medical training — is small and already full to

overflowing in many places. In more than two-thirds of the states, treatment clinics are already at or approaching 100 percent capacity.

The new demand could swamp the system before even half of the newly insured show up at the door, caus-

ing waiting lists of months or longer, treatment agencies say. In recent years, many rehab centers have been shrinking rather than growing be-cause of government budget cuts for patients who receive public support.

"Advocates just get so excited, but at some point, reality is going

to hit and they'll find it's not all it was cracked up to be," said Josh Archambault of the Pioneer Institute, a nonpartisan public policy research center in Boston.

In the coming years, treatment programs and medical colleges will face pressure to ramp up to create a larger system.

But until then, addiction treatment may represent an extreme example of one of the Affordable Care Act's challenges: actually delivering the care that people are supposed to receive.

Many with substance problems are waiting eagerly for January, when the new insurance will become available.

"It's the chance to clean up and not use anymore, so I could live a stable life," said 30-year-old Ashley Lore of Portsmouth, Ohio, who was jailed and lost custody of her 4-year-old daugh-ter as a result of her heroin addiction. "If I get into treatment, I get visitation to my daughter back. And I get her back after I complete treatment."

Only about 10 percent of the 23 million Americans with alcohol or drug problems now receive treat-ment, according to the National Sur-vey on Drug Use and Health. Shame and stigma are part of the reason but about a quarter of them don't have

Addiction treatment now covered,but are there enough facilities?

Continued on next page

Associated PressChicago

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 19

Men in the detox waiting room in Haymarket Center in Chicago hope for one of the few beds open each night. AP File Photo/M. Spencer Green

insurance coverage. That compares with the overall uninsured rate of 16 percent.

With money for treatment limited, slots in rehabilitation centers and hospitals are scarce.

Life or deathInsurance can mean the difference

between getting a spot or waiting in-definitely for publicly subsidized help.

Michelle Hines, an Illinois mother, had both experiences when her 19-year-old son became part of a dis-turbing new trend: suburban teenag-ers hooked on heroin.

Because he was uninsured, the wait would stretch to a month or six weeks for a public bed. His parents, who own a small business, couldn't afford the $2,000-per-month injec-tions to block the heroin high. Over-all, outpatient programs cost about $10,000, and a residential treatment stay about $28,000.

Everything changed after her son was able to get coverage under the family's insurance because of an early benefit of the Affordable Care Act.

They now pay only $40 a month for the shot that helps him stay clean. "He's working hard at getting his life back together," Hines said. "He's in school full time; he's got a job." (Michelle Hines asked that her son's name be withheld to avoid hurting his future employment prospects.)

Nine alumni of Hines' son's high school have died from drug overdos-es. "A waiting list for a heroin addict could mean death," Hines said. "So many have died waiting, it's awful."

Today, those without insurance include many lower- and middle-income people who don't get the benefit from an employer — busi-nesses provide coverage for about 50 percent of Americans — don't qualify for Medicaid or Medicare and can't afford their own policies.

The new law would provide subsi-dies to help many buy private cover-age. The government is also pressing states to expand their Medicaid pro-grams to include more working poor people. If 24 states expand their Med-icaid programs — roughly the number now planning to do so — an additional 4 million prospective patients with addiction problems would get insur-ance, according to the AP analysis. If virtually all of the states eventually

decide to expand, as federal officials predict, the ranks of the newly in-sured with addiction problems could reach 5.5 million.

Perhaps as im-portant as the ex-pansion, the new law designates addiction treatment as an "es-sential health ben-efit" for most com-mercial plans.

"This is probably the most profound change we've had in drug policy ever," said Michael Botti-celli, deputy director of the Office of Na-tional Drug Control Policy. "We know one of the most sig-nificant reasons for the treatment gap is folks who don't have insurance or who have an inadequate coverage package for substance use disorders."

But will those who suddenly get coverage for treatment have a place to get it?

Haymarket Center in Chicago illustrates what may await many ad-dicts. One Friday morning, seven men slumped in chairs in a small, bare room with only an untouched rack of health brochures to break the monot-ony of waiting for the chance of a de-

tox bed that night. The six-story brick building is a beehive of programs for 300-plus patients: short term detox, long-term residential treatment,

recovery units where people can live sober while looking for work. Everything is overbooked. On this day, the waiting list totaled 91 people who want help.

"Last year the state cut our dol-lars so we had to cut back our beds," said Dan Lustig, vice president of Haymar-ket, which gets most of its funding from the government. "We had clients literally

pleading for services. Some were sleeping on our front steps."

Not enough docsIn Illinois, where 92,000 people

get treatment now, nearly 235,000 addicts and alcoholics without insur-ance will be able to get coverage next year. Not only beds are lacking. The pool of physicians who are addic-tion specialists must grow by 3,000 nationwide, almost double what it is now, to handle the demand, accord-ing to health industry experts.

"The big question for providers is how do we bridge the gap between now and then?" said Bruce Angleman of Heritage Behavioral Health Center, which provides treatment in Decatur, in central Illinois.

There are also questions about how comprehensive and affordable the new coverage will be. Consum-ers or their employers who choose cheaper policies with high out-of-pocket costs may find themselves unable to afford their share of an expensive program.

The future ideal may end up look-ing something like the care Shavonne Bullock receives in a neighborhood clinic in Chicago, the metro area with the highest rate of heroin-related emergency room visits. Seven years into her recovery, Bullock, a 54-year-old former heroin addict, still gets counseling and takes medication — "my blessing" she calls it — at the Access Community Health Network clinic to suppress withdrawal symp-toms and reduce craving.

Her doctors and counselors work together. They recognize that addic-tion is a chronic condition, like diabe-tes, that needs maintenance.

"I haven't thought about drugs in seven years," she said. Treatment, she said, "works if you work it. It's all up to the individual. And it really works."

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 20

Zack Romines, 18, left, Adrian Verdugo, 9, center, and Raymond Begay, along with others of Native American descent, tap into the healing rhythms of tribal drumming at the Sacramento Native American Health Center, Feb. 20, 2007. Drums play a huge role in the healing process at the Indian clinic. MCT/Sacramento Bee, LEZLIE STERLING

Associated PressSioux Falls, S.D.

Insurance enrollment helpers are encouraging Native Americans to sign up for coverage under the nation's new health care law, saying it will help them better access X-rays, mammograms, pre-scription drugs and trips to specialists not covered under Indian Health Service.

American Indians are exempt from the Afford-able Care Act's requirement that people carry insurance, but the law opens up resources that for years have been limited through IHS, said Jerilyn Church, executive director of the South Dakota-based Great Plains Tribal Chairmen's Health Board.

"There's a huge gap in access to services, so being enrolled in the marketplace is going to make a big difference in terms of accessibility to health care," Church said.

The Indian Health Service, a branch of the U.S. Department of Health and Human Services, provides free health care to enrolled members of tribes, their descendants and some others as part of the government's treaty obligations to Indian tribes dating back nearly a century.

Critics long have complained of insufficient financial support that has led to constant turnover among doctors and nurses, understaffed hospitals, sparse specialty care and long waits to see a doc-tor.

The Great Plains Tribal Chairmen's Health Board received $264,000 in South Dakota and $186,000 in North Dakota to assist with Indian sign-ups on the states' reservations and urban areas.

The new law health care law will especially benefit people who seek treatment at urban Indian health clinics, which collectively are funded by just 1 percent of the IHS budget, said Ashley Tuomi, ex-ecutive director of the American Indian Health and Family Services clinic in Detroit.

"Our resources are extremely limited, even more

so than the tribes," Tuomi said. "What we have within our walls is what we can offer for free."

The clinic has seen a lot of patient interest in the health care marketplace, but "navigators" helping with sign-ups have had to cancel many appoint-ments because of continued issues with the federal healthcare.gov website, Tuomi said.

The Ponca Tribe of Nebraska has received about $38,000 in federal grant funds to encourage sign-ups for tribal members scattered in 12 coun-ties in Nebraska, two in Iowa and one in South Dakota.

The tribe's IHS-contracted clinic in Omaha, Neb., has a medical doctor and two nurse practitioners, but the X-rays, specialists and prescriptions that

Funding has long been scarce for Native health programs

are outsourced are not covered, said Jan Hender-son, the tribe's navigator project director. "And if they don't have insurance, they have to pay for it themselves," she said.

Tribes across the country get some federal money for referrals, but the small pools run out quickly, Henderson said.

She views the new health care law as a great step for Indians, but the greatest challenge is edu-cating tribal members who are weary from decades of promises of improved health care.

"Education is very important in this right now to get people to be open to actually hearing about it," Henderson said. "We hear a lot of people who say they don't need this, they don't want this."

Resources now availablefor Indians

High costs have traditionally caused many Americans to skip out on crucial preventive care services, as some experts estimate that peo-ple seek out preventive care at half of the recommended rate.

That is a staggering number con-sidering the powerful impact that preventive services can have on curbing dangerous diseases and debilitating illnesses.

The Affordable Care Act aims to substantially increase the utilization of preventive care services by mak-ing many of them free.

If your plan is eligible for free pre-ventive care, you may not have to pay a copayment, co-insurance or deductible to receive the recom-mended services that can help foster longer, healthier lives.

Chronic DiseasesChronic diseases are responsible

for 7 of 10 deaths among Americans each year and account for 75 percent of the nation’s health spending, according to the Centers for Disease Control and Prevention.

An even more alarming fact is that these diseases are often pre-ventable. So why are they not being caught early enough in some cases?

Some experts blame cost sharing — copayments, co-insurance and deductibles — for reducing the likeli-hood that people will seek out pre-ventive services.

The Affordable Care Act requires new health plans to cover and elimi-nate cost sharing for preventive ser-vices recommended by the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices, and the Bright Futures Guidelines recommended by the Academy of Pediatrics.

What is Covered? There is a wide range of services

that could be covered by the

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 21

Focusing on preventive care

© FOTOLIA / AP

The Affordable Care Act requires new health plans to cover and eliminate cost sharing for preventive services recommended by the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices, and the Bright Futures Guidelines recommended by the Academy of Pediatrics.

Affordable Care Act, all of which are necessary to reduce the number of serious diseases and illnesses facing our country.

According to heathcare.gov, these services include blood pressure, dia-betes and cholesterol tests, as well as routine vaccinations against dis-eases such as measles, polio or meningitis.

The law also is designed to cover

individual counseling on topics like quitting smoking, alcohol use, los-ing weight and treating depression.

Services for womenEspecially concerning for

women are studies showing that even moderate copays for preven-tive services such as mammo-grams or pap smears result in fewer women obtaining this care.

Under the Affordable Care Act, women’s preventive health care services — such as mammograms, screenings for cervical cancer, and other services — are already covered with no cost sharing under some health plans. The law also makes recommended preven-tive services free for people on Medicare.

HEALTH CARE REFORM South Bend TRIBUNE | November 10, 2013 | 22

Shopping for better health care deals

Dr. Keith Smith, who started Surgery Center of Oklahoma, looks on during a surgery at the center. AP Photo/SUE OGROCKI

By Tom MurphyAssociated Press

Paul Freeman drove 600 miles last year to save himself — and his employer — thousands of dollars on his surgery.

Freeman's insurer covered his travel costs and the entire bill be-cause a medical center in Oklahoma City could remove the loose cartilage in his knee for about 70 percent less than a hospital closer to Freeman's Texhoma, Okla., home.

At first, the community bank CEO hesitated because he thought the lower price would mean lower qual-ity. But he knew if he didn't make the roughly 10-hour roundtrip trek, he'd pay about $5,000 out of pocket.

"You immediately think, 'Oh they're going to take me into a butcher shop and it's going to be real scary,'" Free-man, 53, says, noting that instead he had a "wonderful experience."

People shop for deals on every-thing from cars to clothes to comput-ers. Why not for health care, too?

Insurers, employers and individu-als are shopping around for health care as they try to tame rising health care costs. Companies are doing things like paying for workers to travel if they agree to have a surgery performed in another city where the cost is cheaper. They're also provid-ing online tools to help people search for better deals near home.

And some patients are bargain-hunting on their own. Through a web-site called MediBid, people who pay out of pocket are soliciting doctors, hospitals and medical centers to bid to perform knee surgeries and other non-emergency procedures.

Patients who shop for care rep-resent a tiny slice of the $2.7 trillion spent annually on health care in the U.S., said Devon Herrick, an econo-

mist who studies health care for the National Center for Policy Analysis. But he and other experts expect this trend to grow, especially as more companies offer insurance that requires employees to pay thousands of dollars before most coverage starts. These high-deductible plans also will be among the cheapest available on the public exchanges set up to enable millions of uninsured people to shop for coverage.

Advocates say all the shopping will help control medical spending.

"We waste an enormous amount of money in this country by overpay-ing for health care," says John Good-man, an economist and CEO of the National Center for Policy Analysis. "The only way to get rid of waste is to have people compete in a real marketplace."

Searching for health care deals is a big change for many patients who're used to paying whatever their insurer didn't. Just figuring out an ap-propriate price for a procedure can be difficult for the average person.

Surgeries and other major proce-dures have different prices based on a variety of factors, including whether it's performed in a big city where care can cost more or in a hospital. And the portion that patients pay can vary widely. A lot depends on the type of insurance coverage and other factors like the leverage a provider has in negotiating rates.

For instance, a patient in Detroit with high-deductible health coverage provided by an employer could pay $920 or $2,791 out of pocket for a colonoscopy, according to research done by health care technology firm Castlight Health. Same patient. Same insurance coverage. Only difference: Where the procedure is performed.

"You can be a highly educated con-sumer now and still not understand

what bill is going to hit you," says Dr. Giovanni Colella, CEO of Castlight, which designs an application that insurers or employers can give to patients to help them shop for health care based on price and quality.

It's also tough for patients to mea-sure quality versus price. "You may find something (more expensive), but it doesn't mean it's better, safer, or more efficient," says Arthur Caplan, a medical ethicist at NYU Langone Medical Center.

Insurers and employers are encourag-ing workers to become more educated. They say quality is a priority when they ask patients if they want a better deal.

Some patients are deal-hunting on their own. The website MediBid, which launched in 2010, connects patients who are paying out of pocket with doctors who bid to provide care. The website's founders say they've helped about 1,800 people find care.

Patients register with the site and pay either $25 per request or $4.95 a month for a year so they can post their medi-cal needs on the site to solicit bids. Care providers, who register and pay fees of either $24.90 per month or about $250 annually, respond to patients with a bid.

Tess St. Clair, MediBid's chief operat-ing officer, says the site helps people weigh their health care options: "The hardest thing for an American to do is ask the question, 'How much will this cost?' and get an answer."

Dr. Keith Smith, with the Surgery Center of Oklahoma, bids often on Medi-Bid requests. Smith says his physician-owned center can offer better rates than some competitors because it doesn't charge a high facility fee like many hos-pitals do. The center competes on price and cuts out insurers.

Smith says this approach forces it to offer good care: The center cannot hide in an insurer's network and continue to receive patients regardless of the job it does.

"If we started cutting corners and worrying about our pocketbook before doing the right thing, we're going to lose our business," he says.

Rick Matthews, a motivational speaker, saved money on his hernia surgery last year by putting it up for bid

on MediBid and having the procedure at Surgery Center of Oklahoma. Matthews, 62, decided to use MediBid after he learned that the care would cost about $20,000 without insurance at a hospital close to his Milaca, Minn., home.

Matthews pays for health care through a Christian cost-sharing min-istry in which members chip in to help cover medical bills. He didn't want to stick them with a big bill. A doctor on MediBid said the surgery would cost about $3,600, including removing a cyst on his knuckle.

Counting costs for the roughly 1,400-plus mile roundtrip drive, Matthews fig-ures the cost was about $4,500 — less than a quarter of the original estimate.

We strive to be a trusted community partner. It’s what we’re called to do.Saint Joseph Regional Medical Center is here to provide you with the information you need about available health insurance plans. With two convenient locations to serve you in Mishawaka and Plymouth, our highly skilled, multi-cultural professionals can meet with you one-on-one to discuss your health insurance options. Learn more by attending one of our Affordable Care Act and Health Insurance Marketplace Basics: Community Education Sessions.

Mishawawaka Plymouth South Bendsjmed.com

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Visit us at sjmed.com/aca or call 855.88.SJMED (855.887.5633) to register for session dates or to schedule your appointment.

St. Joseph CountyWednesday, November 20 • 6 – 7 pm Civil Rights Heritage Center at the Natatorium 1040 W. Washington Street, South Bend

Wednesday, December 11 • 6 – 7 pm Civil Rights Heritage Center at the Natatorium 1040 W. Washington Street, South Bend

Wednesday, January 8 • 6 – 7 pm Saint Joseph Regional Medical Center Mishawaka Campus Education Centers A, B, C (lower level) 5215 Holy Cross Parkway, Mishawaka

Tuesday, January 21 • 4:30 – 5:30 pm Sanctuary at St. Paul’s 3602 S. Ironwood Drive, South Bend

Marshall CountyWednesday, November 13 • 5:30 – 6:30 pm Marshall County Council on Aging 1305 W. Harrison Street, Plymouth

Wednesday, December 4 • 5:30 – 6:30 pm Saint Joseph Regional Medical Center Plymouth Campus, Education Center Medical Office Building 4 1919 Lake Avenue, Plymouth

Wednesday, December 18 • 5:30 – 6:30 pm Marshall County Community Resource Center 510 W. Adams Street, Plymouth

Wednesday, January 15 • 5:30 – 6:30 pm Saint Joseph Regional Medical Center Plymouth Campus, Education Center Medical Office Building 4 1919 Lake Avenue, Plymouth

Wednesday, January 29 • 5:30 – 6:30 pm Marshall County Community Resource Center 510 W. Adams Street, Plymouth

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