Clarence Fanto | The Bottom Line: Embattled Affordable Care Act in need of a tune-up

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LENOX >> For too many Americans, the national medical insurance law has become the Unaffordable Healthcare Act.

The culprits include Republican saboteurs like Marco Rubio; profit-obsessed insurance companies with bloated overhead and scandalously overpaid executives; governors and legislatures in 20 states who refuse to expand Medicaid eligibility funded primarily by Washington; an imperfect law that Republicans in Congress keep trying to kill rather than improve, and some 10 million eligible citizens who would rather risk an average $969 tax penalty per household next year than buy health insurance.

The result is an unstable insurance marketplace, especially for Americans uncovered by their employers, amid widening and withering public criticism or outright opposition to President Obama's historic health care law.

It doesn't help that the administration officials who run the federal insurance marketplaces seem to be downplaying widespread reports of skyrocketing premiums, deductibles, co-insurance (the customer's share of care) and unconscionable prescription drug price hikes, as well as narrowing networks of providers.

The law requires individuals and families to pay close to 10 percent of their gross income (before taxes) for health insurance coverage, but those eligible according to income guidelines get federal subsidies. (For example, individuals with income up to $47,080 can get subsidies; for a family of four, up to $97,000.)

However, a majority of plans offered by the federal marketplace require deductibles higher than $3,000 a year, and the "cap" on annual out-of-pocket costs (including the deductible) can easily exceed $7,000 for a moderate-income family.

Employers' health plans continue to shift more of the monthly premium burden to workers, but deductibles are lower, averaging $1,320 for an individual.

Massachusetts, which runs its own Health Connector marketplace, appears to have recovered from its previously malfunctioning online and telephone enrollment system.

In a media conference call, the CEO of the federal insurance marketplace, Kevin Counihan, claimed that tax-credit subsidies bring monthly premiums down to $75 or less for eight out of 10 purchasers. But those are for basic plans with high annual deductibles and other out-of-pocket costs.

National enrollment is projected at 10 million people by the end of next year, compared to just over 9 million this year, but the predictions are not firm since it turns out that 20 percent of those who sign up for coverage drop out during the year by failing to pay their premiums.

The Rubio legislative sabotage was off the radar until a New York Times front-page article this past week reported that a provision he slipped into last year's federal spending bill "has tangled up the Obama administration, sent tremors through health insurance markets and rattled confidence in the durability" of the health care law.

He succeeded in limiting what the government can spend to protect insurers against financial losses if their claims payments overwhelm revenue — a problem if too many sick people enroll in plans while too many healthy citizens choose to bypass insurance, even at the expense of soaring tax penalties.

The result of Rubio's tactics is that the Obama administration will be able to pay only 13 percent of what insurers were counting on this year to cope with the risks of participating in the federal insurance marketplace. Rubio triumphantly claims victory over "a taxpayer-funded bailout for insurance companies."

But it's the customers who'll be on the hook, and some insurers, notably UnitedHealthcare and 12 of the 23 low-cost, nonprofit insurance cooperatives in a few states, are bailing out by dropping out of the marketplace.

Blue Cross and Blue Shield executives have warned that eliminating the federal payments established by Congress in 2010 to protect insurers could have a devastating impact on insurance markets. But Rubio is pressing to expand the restrictions on federal paybacks to insurance companies in a provision of the spending bill for next year under negotiation on Capitol Hill.

With all these complications, no wonder the health care law remains divisive, with 45 to 38 percent opposed, according to a new poll by the Kaiser Family Foundation.

While conservatives are in full "I told you so" cry, liberals are renewing a push for the "public option" first discussed six years ago — a government health plan competing with private insurers, aka Medicare for all, or a variation on that theme.

"People are sticking their heads in the sand if they say there are not serious problems with the Affordable Care Act," Harvey Rosenfield, founder of the California-based Consumer Watchdog advocacy group, told reporters recently.

"People who were previously uninsured are indisputably better off, but many people in the middle class are struggling," he pointed out. "They are entitled to buy health insurance, but that is an empty promise if the number of doctors and hospitals in your network has shrunk and deductibles have soared."

The law needs a major reboot, but there's no hope of that until after a new president and Congress take office in 13 months. Meanwhile, the Affordable Care Act still deserves support until it can be fixed so that it lives up to its name.

Contact Clarence Fanto at cfanto@yahoo.com


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