King v Burwell

Once again the Supreme Court will have a say about healthcare reform. The Supreme Court has agreed to hear the case King v Burwell. To put it simply, if supporters of this lawsuits succeed, the government will take away premium tax credits from residents in all of the states with federally facilitated marketplaces. Those tax credits help low- and moderate-income people afford to pay their monthly health insurance premiums. Without this benefit, millions would not be able to pay for their health insurance.

The extent of the problem is enormous. More than 7 million people in states with federally run marketplaces currently receive tax credits. But, if they suddenly had to pay unsubsidized premiums, most would no longer be able to afford their coverage.
 
Premium tax credits don’t just help those purchasing healthcare – they increase and strengthen the pool of enrollees helping to create a stronger and more robust health insurance market. In doing so, they help keep health insurance premiums from becoming unaffordable for all of us.

Michigan is one of 34 states that has a federally facilitated marketplace.

 It would affect all the people that we have enrolled in healthcare.

The Supreme Court will hear oral arguments in this case on March 4; we will most likely hear their decision in late June.

 

 

ACA Impact

·       Marketplace enrollment:

o   Nationally, 11.4 million people enrolled in healthcare

o   290,400 people in Michigan enrolled in a Marketplace plan

·       Healthy Michigan Plan enrollment:

o   Statewide - 546,807

o   Hillsdale County - 2328

Special Enrollment Period announced

The Centers for Medicare & Medicaid Services (CMS) announced a special enrollment period (SEP) for individuals and families who did not have health coverage in 2014 and are subject to the fee or “shared responsibility payment” when they file their 2014 taxes in states which use the Federally-facilitated Marketplaces (FFM). This special enrollment period will allow those individuals and families who were unaware or didn’t understand the implications of this new requirement to enroll in 2015 health insurance coverage through the FFM.

For those who were unaware or didn’t understand the implications of the fee for not enrolling in coverage, CMS will provide consumers with an opportunity to purchase health insurance coverage from March 15 to April 30.  If consumers do not purchase coverage for 2015 during this special enrollment period, they may have to pay a fee when they file their 2015 income taxes.
Those eligible for this special enrollment period live in states with a Federally-facilitated Marketplace and:

• Currently are not enrolled in coverage through the FFM for 2015,
• Attest that when they filed their 2014 tax return they paid the fee for not having health coverage in 2014, and
• Attest that they first became aware of, or understood the implications of, the Shared Responsibility Payment after the end of open enrollment (February 15, 2015) in connection with preparing their 2014 taxes.

The special enrollment period will begin on March 15, 2015 and end at 11:59 pm E.S.T. on April 30, 2015.  If a consumer enrolls in coverage before the 15th of the month, coverage will be effective on the first day of the following month.

Special Enrollment Periods

Also known as SEP’s are when a “qualifying life event” takes place. These qualifying life events can include any of the following:

• Getting married
• Having a baby
• Adopting a child or placing a child for adoption or foster care
• Losing other health coverage
• Permanently moving outside your plan’s coverage area
• Losing job-based coverage for any reason, including resigning, getting laid off, or getting fired
• Gaining citizenship or lawful presence in the U.S.

Losing coverage through a divorce

• Gaining or continuing status as a member of an Indian tribe or an Alaska Native shareholder.
• COBRA coverage ending (but not cancelling it yourself before it expires)
• Leaving incarceration
• Aging off a parent’s plan when you turn 26
• For people already enrolled in Marketplace coverage: Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions.
• Losing eligibility for Medicaid or the Children’s Health Insurance Program (CHIP)

·         verage that doesn’t qualify as minimum essential coverage doesn’t qualify you for a Special Enrollment PerIf any of these events occur, and you are interested in obtaining healthcare you can call 1-800-318-2596 or go on-line to healthcare.gov

 

Peg and Paul

Peg has been a patient at the clinic for several years. She comes in once a month to get her medications for high blood pressure. She usually sees the provider once a year or if something unusual comes up. We have been talking to her about insurance for a while, but she was reticent for various reasons. Her husband Paul has healthcare – he is 65 and qualifies for Medicare.

Finally, we convinced her to apply for the Healthy Michigan Plan. She was denied. They made too much money.

Let me explain their situation. It is just the two of them in the household. Between the two of them, they work three jobs. Paul has worked for a local business for over 20 years; he makes $9.50 per hour and typically works 25 hours or less a week. Not because he wants to, but because that is how this particular business operates. He also works a second job. Peg works 24 hours per week, and just got a raise. She will now be making $10.50 an hour.

The two of them, along with their adult daughter, came in to apply for health insurance through the Marketplace. They qualify for Premium Tax Credits, which are applied to the premiums for her healthcare insurance. That brings the premium down to $120 a month. Her raise will almost cover the cost of her healthcare insurance.

For those of us NOT living on the edge of poverty, $120 a month for healthcare seems like a deal. But, when you are just barely getting by and have huge hospital bills from years ago that are still being paid on, well, it is not that easy to make the decision to use your raise to pay for healthcare.

They did make the decision – for peace of mind. They are in their 60s and know that life can change in an instant.

The decision will impact their life. There will be no extra income now – it is all committed to her healthcare insurance.

Why do we make it so hard for people? This is not a problem with healthcare; it is a problem with our society.

Julian

Julian moved back to the area recently. His mom lives in the area – and for various reasons, it was time to come home.

He came to the clinic soon after arriving – he was unemployed, but looking for work and was optimistic about being able to find a job. I talked to him about applying for Medicaid, but he didn’t want to.

He came because he had not been feeling well – general symptoms of anxiety, depression, sleep issues, fatigue, shortness of breath and vague aches and pains. His major symptom was that his neck was swollen.

Given that the symptoms were general and vague, he was treated with antibiotics and blood work was ordered.

He returned a few weeks later with no improvement. The lymph nodes in his neck were swollen and at that time there was suspicion of a mass in the neck area. He was sent for a CT scan.

The lab work was basically normal – no issues were found. The CT scan came back inconclusive – it could be lymphoma, it could be an infection, possibly TB. He needed a specialist.

By this time, he had found a job and was working. Still no insurance, and there is no way to see a specialist without insurance. So he finally consented to apply for Medicaid.

Today, I got word that his TB skin test was positive. And about 5 minutes later, I got word that he had been approved for Medicaid.

He sees the specialist on Tuesday of next week. Without insurance… well, I don’t even want to think about that.

Whatever happens next Tuesday, it will be life changing for him. Now he has insurance, and whether he knows it or not, he has a group of people who are pulling for him. He is not alone in this journey.

In the Blink of an Eye

Dan has been a patient at the clinic for a little over a year. He takes a few medications and sees a provider rarely. He applied for the Healthy Michigan Plan (Medicaid expansion), but was denied. He scheduled an appointment with me to apply for insurance through the Marketplace in December. The day before our appointment, I received a call from his significant other cancelling the appointment because he had just had surgery at the University of Michigan.

He had suffered from a detached retina. Retinal detachment is an emergency situation in which vision can be permanently lost.

Retinal detachment describes an emergency situation in which a critical layer of tissue (the retina) at the back of the eye pulls away from the layer of blood vessels that provides it with oxygen and nourishment.

Retinal detachment leaves the retinal cells lacking oxygen. The longer retinal detachment goes untreated, the greater the risk of permanent vision loss in the affected eye.

Retinal detachment itself is painless, but retinal detachment warning signs and symptoms almost always appear before it occurs or has advanced. Retinal detachment symptoms may include:

• The sudden appearance of many floaters — small bits of debris in the field of vision that look like spots, hairs or strings and seem to float before the eyes
• Sudden flashes of light in the affected eye
• A shadow or curtain over a portion of the visual field that develops as the detachment progresses

 

Retinal detachment can occur as a result of:

• Shrinkage or contraction of the vitreous— the gel-like material that fills the inside of the eye. This can create tugging on the retina and a retinal tear, leading to a retinal detachment.
• Injury
• Advanced diabetes
• An inflammatory eye disorder

 

Dan does not know what caused his retinal detachment. But, he was lucky that it was recognized and he was sent to the proper place for treatment. He won’t lose his vision. And his care was provided by the University of Michigan’s Charity Care.

Once he recovered, he came in to apply for healthcare coverage. He is lucky, because before the implementation of the Affordable Care Act, he would not have been able to get insurance because of his pre-existing condition: the retinal detachment. Now he can get coverage and it will cover any medical care that still may be needed for the detached retina. He is a lucky man.