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Who Gets Covered Under Health Reform?

Who Gets Covered Under Health Reform? As the debate rages over 'Obamacare,' here's a look at what the changes will mean. WebMD Medical News By Brenda Goodman, MA Reviewed by...

June 29, 2012 -- The Supreme Court decision to uphold key provisions in the Affordable Care Act, or ACA, cleared up one question: Will the law stand (for now)? But for many people, that was about all they found clear.

There's still a lot of confusion about who will be covered, will the goal of insuring the uninsured be met, and what happens if I have preexisting conditions?

The court's decision did put a kink in President Obama's plan to extend health insurance to an estimated 32 million uninsured Americans.

More than half of the people meant to gain coverage under the health reform law were supposed to get free coverage under a major expansion of the Medicaid program.

That means, if you're struggling to make ends meet, you wouldn't pay a dime.

Now there's a hiccup in that plan.

After yesterday's decision, states cannot be forced to participate in the Medicaid expansion. That could leave millions of Americans without the coverage promised under the law.

"You've got a lot of conservative governors saying, 'You can't force us to expand Medicaid this way. We can't afford it,'" says Robert Laszewski, president of Health Policy and Strategy Associates in Alexandria, Va.

"Now the court has said, I think very appropriately and fairly, the feds can't take the original Medicaid funding away if you don't do the expansion," Laszewski says.

In effect, the ruling forces states to "put up or shut up," he tells WebMD.

"You don't want the money? You don't have to have the money. But then you go face your constituents and tell them why you didn't expand Medicaid like the other states," he says.

Who Pays for What?

Here's what the numbers look like. From 2014 to 2016, the federal government pays the entire cost of the Medicaid expansion. After 2016, the portion of the costs paid by the federal government begins to decline. By 2020, states would have to kick in 10%.

Ten percent may not sound like much, but some states are saying it could be financially crippling.

In Georgia, a state that sued to block the ACA, Gov. Nathan Deal says he's weighing his options.

''Even with federal help, the state would have to find another $4.5 billion over the next 10 years to pay for the Medicaid expansion.

In Indiana, Gov. Mitch Daniels said in a statement that the expansion would put 1 in 4 Hoosiers on the Medicaid rolls at a cost to the state of $2 billion over the next 10 years.

"I think states will turn it down," says Marc K. Siegel, MD, an infectious disease expert at New York University's Langone Medical Center in New York City, and also the physician coordinator of Doctor Radio.

"In New York, it's a billion dollars or more to administer the Medicaid expansion. So a key problem here is not in terms of Medicaid, which the feds are picking up the cost of for the most part, but the administration of the additional Medicaid patients," Siegel says.

Fate of Medicaid Expansion in States' Hands

Medicaid is a government program that helps the poorest Americans get health care. One in four people insured under Medicaid are children.

"The Medicaid program is financed as a partnership between the federal government and the states," says Andrew Bindman, MD, a professor of medicine, health policy, epidemiology and biostatistics at the University of California, San Francisco. Bindman helped to draft the ACA, and he worked on the Medicaid expansion plan.

According to a report by the Kaiser Family Foundation, the federal government pays an average of 57% of the cost of Medicaid. States pick up the rest of the tab.

As it stands, the income cut-offs for Medicaid are very restrictive. Many people fail to qualify if they earn minimum wage.

The Medicaid expansion increases the income cut-off to 133% of the federal poverty level. The level is adjusted each year. But in 2012, for a family of four, the level is $23,050. The new law would bump that up to $30,657.

Currently, an estimated 50% of people who don't have health insurance would qualify for the Medicaid expansion under the ACA.

But only if the state you live in decides to participate.

"The good news is that we're expanding coverage for the uninsured. Concern remains for some of the most vulnerable, because the Medicaid provisions of the law could be interpreted differently from state to state. It's possible that states may choose to opt out of the program with a negative impact on poor people," says Rachel Garfield, a senior researcher with the nonprofit private foundation Kaiser Family Foundation.

What About Preexisting Conditions?

In the past, many people who have tried to buy their own health insurance on the open market have been dealt disappointment: Based on something in their past medical history, the insurance company declined to cover them.

In some cases, these so-called "preexisting conditions" are chronic diseases that need lifelong care, like diabetes, rheumatoid arthritis, allergies, or asthma.

In other instances, though, preexisting conditions don't seem quite as serious. They can be anything from a past bout of sinusitis to an old sports injury.

People deemed to have a preexisting condition can sometimes buy health insurance, but any doctor's visit related to the condition may not be covered under the plan they are offered.

The ACA blocks insurance companies from denying anyone coverage on the basis of a preexisting condition, and it prevents insurance companies from charging sick people more.

"That goes away in 2014. Everybody's premiums will be the same," says Sara Collins, PhD, vice president for Affordable Health Insurance at the Commonwealth Fund.

In fact, it's already gone away. If you need health insurance, but you've been turned down because of a preexisting condition, the ACA has already established insurance plans that will cover you.

As long as you can prove that an insurance company has denied you coverage, and that you've been uninsured for at least six months, you can apply for coverage through a high-risk pool, which is also called a preexisting condition insurance plan, or PCIP.

The plan premiums vary by age and state. You can find out how much a plan would cost by visiting the federal department of health and human services at HHS.gov. Those plans will be phased out after the law takes effect in 2014.

Jeff Levine contributed to this article.

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