How healthy are the Affordable Care Act marketplaces?

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• JUDY WOODRUFF:

  But first: What's next for the future of the Affordable Care Act and the consumers who are using it?

  After the Republican bill was withdrawn on Friday, House Speaker Paul Ryan said — quote — "Obamacare remains the law of the land" for now.

  But there are problems that need to be addressed. President Obama himself has said so. More than 20 million people are now getting coverage through the insurance marketplaces and a Medicaid expansion.

  Lisa Desjardins looks at the big questions ahead.

• LISA DESJARDINS:

  One major issue: the health of the marketplaces for individuals who get insurance on their own. For them, premiums rose by an average of 25 percent this year. What's happening? In part, the exchanges need more younger and healthier adults to enroll.

  Our team has been fanning out across the country to hear about Americans' concerns.

  We start with a small business in Salt Lake City, and younger adults who are not buying coverage now.

• PATRICIA SMITH, Manager, Camp Bow Wow:

  My name is Patricia Smith. I'm 33 years old, and I'm the manager at Camp Bow Wow.

  Before the ACA, it was much more reasonable for me to be able to afford insurance. The health care act came up, and although the first time when I applied, I was able to get subsidies, when I filed taxes at the end of the year, they ended up telling me that, as a matter of fact, I shouldn't have been able to get subsidies, and I had to pay all of them back.

  Moving forward, from that point on, I was really not in a position to be able to afford health insurance anymore. If I had chosen to get insurance, the cost of living for me would've changed. My grocery bills, I wouldn't be able to afford. My gas, my mortgage. It really would take a toll on everything.

  I definitely do worry about not having insurance. There's a lot of what-ifs. Even last year, I took a tumble down the stairs and ended up in an InstaCare. And there's just a lot of worries that go with that.

• JOHN GARRETT, Front Desk Associate, Camp Bow Wow:

  I'm John Garrett. I'm 24 years old, and I am a front desk associate here at Camp Bow Wow.

  I'm not very worried about not having health insurance at the moment, because I'm pretty young, and I don't have that much going on with me. So if I can, you know, afford to skip that bill and save that, that much money a month, I definitely would prefer to do that.

  We did have to pay a penalty for not having health insurance. So, the first year, it was about $200. And that wasn't a big deal at the time. The next year, I think it was double, about $400, and then the year after that, it was $700.

• PATRICIA SMITH:

  I think it's a little silly for me to have to pay for something that I simply can't afford anyways.

  Moving forward, if the law is supposed to change and we're able to afford health insurance and we were able to get money back and things like that to pay for it, I would love to put money in health insurance, so that I don't have to have the worry that I have right now.

• LISA DESJARDINS:

  At the same time, there are concerns about out-of-pocket costs.

  Let's meet a woman in Ohio who has a chronic health problem and is grateful for the coverage she receives through the Affordable Care Act. She was politically active in opposing the Republican bill, but says even the current law could be improved.

• MINDY HEDGES, Diabetes Patient:

  My name is Mindy Hedges. I live in Radnor, Ohio, Delaware County. And my age is 61.

  Well, I'm a Type 1 diabetic. I have been a Type 1 diabetic since the age of 5. That means a lot of medication. And I test myself, my blood sugar, about six to eight times a day. It is a lot of medicines that I need to take.

  I'm on an insulin pump, very expensive. My pharmaceuticals are about $1,200 a month.

  I had my own company for 18 years, and the recession hit and the business closed. I tried to get insurance and couldn't. Nobody would cover me because I have a preexisting condition.

  And of the companies that talked to me at all about how much it would cost, it was between $2,500 to $5,000. And even at that, they also wouldn't cover me.

  So, I was begging for — people were giving me supplies. I had a friend that worked in the medical field that was giving me insulin and syringes.

  I was waiting for the Affordable Care Act to get passed. Finally, it did. And I was so thankful.

  We pay a substantial amount, but I still get a subsidy for it. My payment right now is $445 a month. And it's not a system that is … that is pure. And I'm sure that it has some things that need to be fixed.

  And if only we could just fix them, instead of coming up with something that is so totally broken.

• LISA DESJARDINS:

  That's a sampling of the concerns we heard across the country.

  Let's get our hands around what exactly will happen now with health care. Problems remain, but how will insurers and all of us handle them?

  Mary Agnes Carey of Kaiser Health News is here to walk through some of these issues.

  Thank you for joining us, Mary Agnes.

• MARY AGNES CAREY, Kaiser Health News:

  Thanks for having me.

• LISA DESJARDINS:

  Let's start with something President Trump said on Friday. Listen.

• PRESIDENT DONALD TRUMP:

  I have been saying for the last year-and-a-half that the best thing we can do, politically speaking, is let Obamacare explode. It is exploding right now. Many states have big problems. Almost all states have big problems.

• LISA DESJARDINS:

  Now, it's obviously a piece of rhetoric, but it is certainly echoed around Washington.

  I will just ask you right away: Will Obamacare explode? Is that accurate? And regardless of the answer of at the question, where are the real problems now?

• MARY AGNES CAREY:

  I don't think it will explode. There are definitely some problems with affordability. You mentioned that average 25 percent increase in the federal exchanges.

  Rural areas, the prices tend to be higher. Urban areas, the prices tend to be lower. So, it really depends on where you live. Are insurers getting into that market? How much competition is there between the doctors and the hospitals, that sort of thing, with the providers in the marketplace?

  But there's a lot of variance. Let me give you an example. For this year, in 2017, for one of the plans offered on the exchange, for a 40-year-old nonsmoker in Louisville, Kentucky, it was $229 a month. That same premium in Anchorage, Alaska, was $904, but this is before the subsidies that help eight in 10 people in the exchanges lower that price.

• LISA DESJARDINS:

  And so it seems that rural areas, Anchorage might be an example, those are the ones where we see the biggest problems.

  Now, Congress, it seems, is not planning to do anything to repair the system, at least in the foreseeable future. But insurers have no choice. They have to take action. What are the decisions facing insurers coming up soon?

• MARY AGNES CAREY:

  Sure.

  They have to decide by June — it was May, but the administration moved it back because of all the uncertainty over the health care debate we have both been covering on Capitol Hill. So, by May, they need to get — by June, rather, they need to get in their premium estimates.

  And so they will be looking at their experience in the market. Who are they covering? How sick have these people been? We know that the sickest folks came in first. They're very, very expensive. Some have thought that 25 percent premium jump is going to be sort of a one-time anomaly. Will that even out for 2018?

  What's the competition in the marketplace? Are other insurers there looking at their risk pool, all the people they're insuring? They're trying to get a full look at everything. And they will also be wondering if the Trump administration will enforce this thing called the individual mandate.

  This is a requirement that most Americans have coverage or pay a fine. Insurers like it because it makes the healthy and the sicker people get in.

• LISA DESJARDINS:

  Like the younger people that we heard mentioned in the piece.

• MARY AGNES CAREY:

  Exactly.

• LISA DESJARDINS:

  That was obviously something they were thinking about, that penalty.

• MARY AGNES CAREY:

  Right.

• LISA DESJARDINS:

  The question is whether the Trump administration will actually force them to pay it.

• MARY AGNES CAREY:

  Right, because the younger people tend to be healthier. And the more of those folks that are in the risk pool, the better off, the lower the premiums, usually.

• LISA DESJARDINS:

  All right, Republicans still have the Health and Human Services secretary, Tom Price.

  What power does he have? What decisions is he thinking about right now when it comes to the Affordable Care Act and our health care system?

• MARY AGNES CAREY:

  Sure.

  He could do some things administratively. We have to remember the Affordable Care Act gives the Health and Human Services secretary lots and lots of power.

  He could examine these things called the essential health benefits, those 10 categories that include maternity care, emergency services, mental health services, and perhaps give insurers a little more flexibility over whether or not they have to offer those.

  When you talk about the Medicaid program, they may be a lot more open to new approaches from states, including work requirements for the Medicaid beneficiaries.

  And back to the Affordable Care Act, there is this other area of subsidies. There's premium subsidies, there's cost-sharing subsidies. They're part of a legal battle, but the bottom line is: The Trump administration and Republicans in Congress could decide not to fund these.

  About 60 percent of people who get help on the exchanges get the cost-sharing. They help with the co-pays and other out-of-pocket deductibles. And if they did, they would have quite a problem with the insurers.

• LISA DESJARDINS:

  And so to be clear now, that is not the general subsidies people get to get insurance.

• MARY AGNES CAREY:

  No.

• LISA DESJARDINS:

  That is help for people to pay when you get to the doctor, your deductible and all of that.

• MARY AGNES CAREY:

  That's right, your out-of-pocket.

• LISA DESJARDINS:

  And the Republicans could decide not to provide that money. Insurers are worried, if Republicans don't, then they are going to have people who don't pay.

• MARY AGNES CAREY:

  That's right. If they don't have the money, they can't make the deductible. They can't make the co-pay.

  So, if they went ahead with that, they could have some pushback from the insurers.

• LISA DESJARDINS:

  So, briefly, I guess, to sum all this up, at the end of the day, what should people be thinking about and how much — what should people watch to see if their life will change under health care?

• MARY AGNES CAREY:

  First of all, I think take a breath. This has been kind of confusing for people, all the fights on Capitol Hill, what is happening.

  Look at your own health insurance situation. If you're on the exchanges or thinking about them, as we head into fall with the next open enrollment period, see what your options are.

  Healthcare.gov is the electronic marketplace. You can get on healthcare.gov. You can work with a broker, an insurance agent. Who's offering coverage? Is your current plan there? Are your providers covered? What's your total cost on your premium and your out-of-pocket?

• LISA DESJARDINS:

  A lot to be watching for.

• MARY AGNES CAREY:

  A lot.

• LISA DESJARDINS:

  And I know you will be watching with us.

  Mary Agnes Carey, thank you so much for joining us.

• MARY AGNES CAREY:

  Thank you.