ACA explained at Dolores meeting

S.W. Memorial, Piņon Project have guides outlining health reform

Forty Dolores residents filled the library commons room to learn about the Affordable Care Act, its pluses and minuses, along with discovering a few ambiguous aspects.

Thea Wagler, a certified health coverage guide, walked the crowd through the new law, but limited discussion to individual health plans under the ACA, also known as Obamacare.

"Explaining the options for businesses is a whole other ball game," she said at the gathering held Oct. 1.

Key aspects of the law are that it holds insurance companies accountable, and cannot deny pre-existing conditions for people who are sick and trying to get insurance, Wagler said.

Health plans bought through the ACA market exchange must spend 80 percent of the premium dollars they take in on health-care costs. If they do not, they must provide refunds to policyholders.

"Overall the ACA is designed to provide Americans with better health security. It's exciting when the government does something to help the people," she said. "It also ends the practice of charging more for sicker people, or women, and cancelling policies when people get sick or injured."

Other advantages noted are that parents can continue to list their children on their health-care plans up to the age of 26, regardless if they live with the parent. Also, health plans must cover a set of preventive services such as shots and screening tests at no cost.

Prevents moochers

A key component for making the ACA work is that it is a collective where everyone signs up and contributes money.

"It is a shared-risk pool. That way, if you get sick or injured, you are covered. It would not be fair if someone who does not contribute gets coverage at the expense of everyone else," Wagler said. "It is designed so there won't be uninsured Americans leaching off the system."

As incentive, the ACA requires that most individuals must have health insurance by January 2014, or face a penalty. The penalty for not having insurance the first year is $95 per adult, and $47.50 for a child, up to $285 per family. The penalty will increase every year thereafter.

"I've never been sick, I work hard to keep healthy and so I choose not to have health insurance. I'll just pay the penalty," said middle aged woman. "Even if it is $600 per year, it is still cheaper than what is available for me."

"It is a roll of the dice to not have insurance," Wagler responded.

No one can predict a car wreck, natural disaster, random accident, or sudden disease.

However, the individual mandate to purchase insurance does not apply if your income is less than $10,000 for an individual, or less than $20,000 for a family.

Other groups or people exempted from buying insurance are: members of an Indian tribe, undocumented immigrants, religious groups who oppose health-insurance benefits, or the incarcerated.

Where to sign up?

First off who is eligible for ACA plans: The new marketplace for health insurance is for those who are insured on their own, uninsured, self-employed, or do not have access to affordable coverage through their employer.

States that passed legislation to support the ACA have their own websites to buy insurance plans. Residents of states that do not support the program can still sign up because it is a national law, and they can do so on a federal government website.

"Colorado agreed to support the law early on, and is ahead of the curve on its website design," Wagler said.

Coloradoans should go to to shop for and sign up for health-insurance plans that meet their needs. The federal website is and can be accessed by any U.S. citizen in any state.

How much it will cost individuals and families is explained on the website. In general prices depend on age, region, family size, and tobacco use.

"Colorado will charge 15 percent extra for insurance for tobacco users because they are a higher health risk," Wagler said.

Available plans categorized as bronze, silver, gold, and premium. For bronze, 60 percent of medical care costs are paid by insurance, and 40 percent is paid for by the patient. For silver plans the split is 70/30, gold 80/20, and platinum 90/10. The more medical services paid for by the insurance company, the higher the premiums.

Pre-existing pitfall

Wagler said one pitfall to avoid is to study plans closely to make sure they cover your pre-existing condition. But it wasn't clear what would happen if a disease or condition became an issue after insurance that did not cover it was obtained.

"It seems to contradict itself," said another woman. "They say pre-existing does not matter, but then your plan might not cover a new disease you get after. Then you have to upgrade to a higher-cost plan."

For many, seeking so-called catastrophic insurance has been the norm. High deductibles and low premiums are preferred among the young and healthy.

But for those eligible for ACA plans, catastrophic insurance is only available for individuals younger than 30.

"How much would it be for me to get insurance, in case I break my neck snowboarding?" asked a young woman in her early 20s.

"Your premium could be as low as $187," Wagler said.

"Is that per year?" the woman asked, slumping when realizing it's per month. "That is expensive. I can barely pay my rent with what I get paid."

ACA is designed to better assist the working poor, Wagler explained.

Expanded Medicaid

Under the ACA, more people will become eligible for Medicaid, a federal program assisting the poor. It is different from Medicare, which is health care for those 65 and older.

Beginning in 2014, Wagler said, individuals earning up to 133 percent of the federal poverty level will become eligible for Medicaid, which would provide full health coverage.

For an individual to qualify they would have to earn $15,282 per year or less. A family of four earning $31,322 per year or less also would qualify.

It is estimated that there will be 160,000 newly eligible Coloradans who could enroll in Medicaid.

How income is measured was also brought up at the meeting.

A man who is married and files taxes jointly with his wife may show a higher household income and not qualify for reduced premiums or the expanded Medicaid program.

"I'm wondering if I should file separately now if it means I qualify for a better deal?" But whether he should was not known.

In the end, the program is a benefit for the people, Wagler said.

"It subsidizes health care and will probably help you. We all pay taxes, it is about time they gave back," she said. "Because everyone pays in, the younger help cover the older, and then it balances out as people age and need medical care."

Southwest Memorial and the Piņon Project (300 N. Elm) both have health care guides available to assist people seeking health insurance under the ACA. The service is free of charge.