This week opens the six-month window for uninsured people to figure out how and whether they'll get coverage under the new system created by the Affordable Care Act. For some, it will be a time of punching their age and income into an online calculator and coming to know the words "bronze," "gold," "silver," and "platinum" as plan options rather than precious metals. For others, this first open enrollment period will bring news that they're newly eligible for Medicaid benefits. And for others, not much will change because their state's political leaders have rejected a piece of the ACA that promises to improve health outcomes for poor and low-income people.
Eventually, when all the conjecture is replaced by observable evidence, we'll be able to draw conclusions about just how well healthcare reform is working and for whom. In the meantime, here are three questions to keep in mind.
Will Kentucky put the rest of the South to shame?
Look at a map of which states have decided to expand Medicaid by raising household income eligibility to 138 percent of the federal poverty level, and you'll see the Southeast cordoned off like a big block of "no." Legislatures and governors there have taken advantage of the Supreme Court's ruling last year that this aspect of the ACA should be left up to state decision makers and can’t be mandated by the federal government. But many of these politicians are acting against the will of their constituents, as poll results released this summer revealed.
Malika Redmond, executive director of SPARK Reproductive Justice NOW, is one such constituent. Last month, she stood outside the Georgia State Capitol along with representatives from the Atlanta chapter of the National Domestic Workers Alliance and demanded that Republican Governor Nathan Deal reverse his position and agree to expand Medicaid.
Redmond's reproductive justice work puts her in touch primarily with LGBTQ youth of color between the ages of 18 and 25 and with black women. She says these populations struggle to find secure jobs and that inconsistent income makes it hard to commit to a premium (or monthly payment on a health plan), even with the government subsidies that will be available under the new system.
"What happens if you lose your job? What happens if you're in a plan but now you can't afford that plan? In a state like Georgia, it's just too bad," Redmond said. "Medicaid expansion is the only safety net. It's the only piece that allows for the fact that people's lives fluctuate, and sometimes they're employed and sometimes they're not."
The one Southern governor who's gone on record as sharing Redmond's way of thinking is Democrat Steve Beshear of Kentucky, whose op-ed in the New York Times last week explained why his state will make Medicaid more widely available. If you're interested in watching how things unfold in Southern states with obstructionist leadership, keep one eye on Kentucky as a point of comparison.
Will the ACA turn out to be a godsend for women?
In general, women can expect lower premiums now that insurance companies are required to scrap the gender rating system that's traditionally made coverage more expensive for half the population. And for some women, the new system has already brought expanded access to birth control, breast pumps for new moms, and annual well-woman visits that include cervical and breast cancer screenings — all without co-pays.
Reform is also expected to bring changes for parents-to-be. Under the current system, it's up to individual insurance companies to decide whether they want to offer maternity coverage, and only 12 percent of plans sold on the individual market do, according to a report from the Center for American Progress. But under the ACA, it's required of all plans. Nearly nine million women will gain maternity coverage starting in 2014.
Right-wing observers have claimed that the ACA "promotes single motherhood" and that states that expand Medicaid will be subsidizing out-of-wedlock births. But rather than fall for fear mongering about how the new policy threatens traditional family structures, we should watch to see how the ACA affects people's choices around reproductive health.
Do the "young invincibles" really think they're invincible?
The health insurance industry came up with this characterization as a way to talk about the 18- to 34-year-olds on whom so much of the ACA's success depends. In order for health care companies to take on people who were previously barred from coverage because of so-called preexisting conditions, there has to also be an influx of young, healthy enrollees who can help offset new costs. But will your average healthy young person commit to paying a monthly premium when it may be less expensive to pay the new penalty associated with not having coverage?
So goes the conundrum surrounding millennnials' participation in the system. But Tamika Butler says the question rests on a false premise: Young people actually don't think they’re invincible. Butler directs the California office of the Young Invincibles, an organization that took on the label and set out to correct the misconception. Her belief is backed up by a recent Kaiser Family Foundation poll that found that about 70 percent of young people consider being insured "very important."
"Young people do care about health care, they just haven't had affordable options," Butler said. "Young people use the ER at a higher rate than any other age group under the age of 75."
Butler said the key to ending this reliance on emergency rooms is preventive care and establishing regular contact with a doctor so that anything abnormal is detected before it turns into a crisis. Once young people understand that they may be newly eligible for a subsidy or for Medicaid, they'll consider the alternative and sign up in droves, Butler said.
"What happens when you go to the ER for one night and you spend the same amount of money that you could use for tuition for one semester?" she said, repeating the question she puts to young Californians.
In addition to watching whether young people decide the changes to the healthcare system are good for their long-term financial stability, it'll be worth observing whether new options shift their habits. That's what Malika Redmond in Georgia wonders when she talks to the teenagers and twenty-somethings who participate in SPARK's programs.
Often they haven't heard much about ACA, she said. When she has gotten them talking, she's quickly realized that a shift in the culture around health needs to accompany shifts in the system.
"To move into thinking about annual exams, getting a physical, getting vaccines, going to a primary care doctor and maybe a specialist — that is really a middle-class conversation," Redmond said. "For folks who have been chronically uninsured, for the working class and the low-income, that's a different way of thinking about your life."