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Part 2: Affordable Care Act: The basics you need to know

By Wes Goforth
Published On: Dec 24 2013 02:56:31 PM CST
Updated On: Nov 18 2013 08:47:32 AM CST

Americans are concerned about their health care. But they are confused by the new health care law. Reporter Wes Goforth breaks down how the reform works.

NEW BERN, N.C. -

Americans are concerned about their health care. But they are confused by the new health care law.

The "Patient Protection and Affordable Care Act," more commonly known as "Obamacare," is an incredibly large and detailed series of laws that began taking effect 3-and-a-half years ago. It's the nation's largest health care reform in a half-century.

The Affordable Care Act is the result of decades of work and debate on how to improve the way Americans stay healthy and how they are treated if they aren't. The cost and complexities of health care have driven government to act.

The A.C.A. requires all Americans, with few exceptions, to have health insurance. That's known as the "individual mandate," and it takes effect in just a few weeks.

"Individuals are required to have health coverage or pay a penalty…and you will have until March 31 of 2014 to look at plans on the exchange," said health care attorney Bridget Welborn.

The penalty for not having insurance is $95 for individuals and up to $285 for a family during the first year, and increases after that.

About 85 percent of Americans are already insured- paid for by themselves, their employer or the government. The Affordable Care Act will try, in several ways, to help uninsured people get coverage and to help others find the most affordable care.

The starting point is an online "Health Insurance Exchange," or "Marketplace." But that website, healthcare.gov, has been plagued with problems since going online Oct. 1.

It's meant to be the central place to compare levels of coverage and price. You begin by entering information about yourself. From there, you can apply for a policy from a company in your state or from the government.
Many people might also be able to get help paying for their health insurance by getting subsidies. The amount depends on income, and it appears a lot of people will qualify.

"You have to be at 100 to 400 percent of the federal poverty level..so there are many people below that. For a single person, that number is around 46,000," said Blue Cross Blue Shield broker Marc Jessup.

A family of four can have an income just more than $94,000 and still qualify for a subsidy. Subsidies won't come in the form of money directly from the government- rather by tax credits, which reduce the amount of tax qualifying people will pay.

Subsidy and tax credit info is also available through your state's online exchange.

Since people will have to have insurance, they'll have to be able to get it. The act includes a rule known as "Guaranteed Issue," meaning insurance companies cannot deny people coverage. "Guaranteed Issue" will change the way health insurance companies do business, by limiting how the industry measures risk and fixes its rates:

"There are only three things you can derive your rates from going forward… how old you are, where you live, and if you smoke. So there's no more underwriting. You can't ask health questions," said Jessup.

Not only does "Obamacare" require everyone to get health insurance, it also requires many employers to offer it or face big penalties. That so-called "Employer Mandate" kicks in on Jan. 1, 2015. Like many other parts of the law, the "Employer Mandate" is evolving. But it basically requires employers with 50 or more full-time workers to provide health coverage deemed "affordable" by the new law, or face penalties. It defines a full-time employee as one who works at least 30 hours a week, rather than the traditional 40.

Some employers fear increased costs of providing health care coverage. They might cut worker hours, reduce the number of employees, or drop health insurance benefits altogether and pay the penalty. So if you have insurance through your job now, it's a good idea to ask if your employer plans to make changes next year.

The full effect of health care reform under the Affordable Care Act won't be known for years. The timetable and laws are evolving, and of course, political disagreement could mean future changes. But we already know some things that are included:

--Insurance companies cannot deny coverage for pre-existing medical conditions or when people get sick.
--There will be no more lifetime coverage limits for patients or spending caps for insurance companies.
--Dependents can stay on their parents' plans until age 26.
--New plans will have several mandatory benefits like mental health and maternity, and will include preventive care.

What about the people who provide health care- the doctors, hospitals, ambulance services, and so on? They too aren't entirely thrilled with the confusion and new regulations. But when it comes to improving America's health care quality, many hope what they see as the very heartbeat of the new law can work.

"But the emphasis that the Affordable Care Act is trying to put is on prevention of illness. You know, we're treating it in the early stages so that it doesn't become so severe and that's a good thing," said Dr. Ron May, V.P. of medical affairs at CarolinaEast Health System.

"And so bottom line here, how will this affect the quality of health care for individuals? Oh gee, that's difficult to answer. I think that for the patients who have not had access to care before, will now have access and I would say their health would improve with access to care," said Stephen Nuckolls, CEO of Coastal Carolina Quality Care, Inc.

"Prevention is always less costly than treatment," said May.