What health care reform means for you

By David S. Hilzenrath • THE WASHINGTON POST • July 13, 2009 As President Obama and Congress try to overhaul health care, almost every American has a stake. Will you get the care you need? Can you avoid financial ruin? The potential upsides and downsides reflect various proposals under consideration. How you fare could depend on the fine print of any legislative compromise — for example, whether you meet the income qualifications for insurance subsidies, and whether those subsidies are enough to allow you to buy insurance. Here's an overview of what you stand to gain or lose. And remember, health care reform could fail to achieve some of its loftiest goals. Costs could continue to soar, quality improvements could fail to materialize, and pressure to cut costs could lower quality of care or disrupt access to medical services. IF YOU'RE UNINSURED Number affected (2007): 46 million HOW YOU COULD BENEFIT FROM REFORM: • If you have a low income, you could have an easier time qualifying for Medicaid, a program funded by the state and federal governments. Proposals by three House committees and the Senate Health Committee, plus a set of options laid out by the Senate Finance Committee, include loosening eligibility standards. • In addition, based on your income, you could receive federal aid to purchase private insurance and vouchers for preventive care. • A common theme of major legislative proposals is that you could gain the option of buying insurance through exchanges, novel arrangements in which insurers would be prohibited from denying coverage for preexisting conditions or taking into account your medical risk when setting your premium. • Insurers in the exchanges would offer a minimum set of benefits. As spelled out in the House "Tri-Committee" proposal, for example, those would include an annual cap on out-of-pocket expenses and an end to co-payments and deductibles for preventive care. • Older people could pay premiums closer to those paid by younger people, because age-based variations in rates could be restricted. • You could gain the option of buying coverage from a government plan or nonprofit cooperative whose scale would enable it to pass along savings. HOW YOU COULD LOSE UNDER REFORM: • You could be required to buy insurance or pay a penalty. Any assistance the government offers may be too small to make coverage affordable. • Young people and healthy people could end up paying relatively higher premiums, if age becomes a less significant factor and medical history ceases to be a factor in setting rates. As young people grow old and healthy people get sick, such sacrifices could even out. IF YOU'RE ON MEDICARE OR MEDICAID Number affected (2007): Medicare, 42 million; Medicaid, 37 million HOW YOU COULD BENEFIT FROM REFORM: MEDICARE • The "doughnut hole" for prescription drug coverage, which leaves you responsible for the cost when you've racked up $2,700 to $6,100 of annual prescription expenses, could be narrowed or closed. • You could obtain preventive services without paying anything out of pocket. • You could qualify for drug subsidies with more assets than current recipients are allowed. • Income from the sale of your primary residence could be excluded from determinations of who pays higher premiums for outpatient coverage. • Premiums could be reduced for seniors who enroll in wellness or disease-management programs. • Payments to primary-care doctors could be increased, paving the way for them to play a larger role in your care. • As outlined in a Senate Finance Committee options paper, your annual out-of-pocket expenses could be capped, protecting you from catastrophic bills. MEDICAID • Increased reimbursements for physicians could make it easier to find doctors. You also could gain access to private health plans. HOW YOU COULD LOSE UNDER REFORM: MEDICARE • Those with higher incomes could be required to pay higher premiums for drug coverage. • To discourage wastefulness, you could face higher outpatient deductibles and lose the ability to purchase "first-dollar" Medigap policies that can spare you out-of-pocket expenses. • Reduced payments to managed care or Medicare Advantage plans could prompt cuts to special benefits such as free eyeglasses and health club memberships. MEDICAID • If you are moved to a private health plan, you might lose special benefits such as hearing aids and eyeglasses for children and transportation to and from the doctor's office. IF YOU HAVE AN EMPLOYER-SPONSORED PLAN Number affected (2007): 158 million HOW YOU COULD BENEFIT FROM REFORM: • If you're employed at a small business, you and your employer could gain the option of buying coverage through an exchange, in which insurers would have to offer a minimum set of benefits, and factors such as health status would not count against you. The government might help your employer pay for health benefits. • If health care reform succeeds in making care more efficient — a big "if" — your costs may rise more slowly than they would without reform. You could get better care as a result of efforts to increase coordination among providers, identify and encourage best practices, automate medical records, avoid unnecessary tests and procedures, and reduce medical errors. • With expanded coverage for the uninsured, you and your employer could experience a reduction in what some call the hidden health tax you now pay to cover the cost of care that hospitals provide without compensation. • If you leave or lose your job and have to buy your own insurance, you could face much better options than those now available to you (see explanation for people who buy their own insurance). Having new alternatives could make it easier for you to leave a job in which you feel trapped; if you get laid off, it could save you from joining the ranks of the uninsured. HOW YOU COULD LOSE UNDER REFORM: • Some or all of your health benefits, which are now exempt from taxation, could be taxed to help pay for covering the uninsured. • Your employer could be penalized for failing to provide health benefits, and whatever affects your employer could affect you. IF YOU BUY YOUR OWN INSURANCE Number affected (2007): 15 million HOW YOU COULD BENEFIT FROM REFORM: • You could gain the option of buying insurance through exchanges, with an annual cap on out-of-pocket expenses, an end to co-payments and deductibles for preventive care, and no more annual or lifetime limits on coverage. • Insurers in the exchanges could be barred from denying coverage based on your medical history. Insurers could be required to cover your preexisting conditions. • Older people could pay premiums closer to those paid by younger people because age-based variations in rates could be restricted. • You could gain the option of buying coverage from a government plan or nonprofit cooperative whose scale and purchasing power could enable it to pass along savings. • Based on your income, you could receive federal aid to purchase insurance. • Your employer could be required to provide health benefits or pay a penalty, increasing the odds that you would receive coverage at work. HOW YOU COULD LOSE UNDER REFORM: • You could face a penalty if you decide to go without coverage. • Young people and healthy people could end up paying relatively higher premiums, if age becomes a less significant factor and medical history ceases to be a factor in setting rates. • The coverage available to you could remain unaffordable.