Answer for uninsured raises questions for Nebraska

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October 10, 2011 - 7:00pm

The health exchange is a cornerstone of the federal health care reform law passed in 2010. By January 2014, health exchanges are supposed to provide one stop shopping where people can compare different health plans and find out if they qualify for a federal subsidy to help pay for it.But the states will have a significant influence in how exchanges work. Two states already have an exchange - Massachusetts and Utah. Thirteen more have exchanges in the works according to the National Conference of State Legislatures. In Nebraska, several groups have been researching what lawmakers will have to decide if the state moves ahead with its own version.

Nebraska has a lower uninsured rate than average. Nationally, 16.5% of Americans are uninsured. Just over 200,000 Nebraskans, 11.5%, are without coverage according to the Nebraska Department of Insurance.

Joel Ruiz

Operations Director, Clinic with a Heart

But those without coverage often find themselves struggling to afford health care. On a Thursday night in Lincoln, Clinic with a Heart opens its doors to uninsured Nebraskans and others who cannot afford to pay for a checkup. Operations Coordinator, Joel Ruiz, says demand has been steady.


Click here for a map from the National Conference of State Legislatures showing how far along other states are in designing a health exchange.

Click here for recommendations from the Institute of Medicine on basic coverage within an exchange.

Graphic by Hilary Stohs-Krause, NET News

Click here for a chart showing the percentage of the population that's uninsured in states neighboring Nebraska.

Click here for a Robert Wood Johnson Foundation report on issues facing states in building health exchanges.

"Last year it was in the 2000s," Ruiz said. "And that was 2000 new visits, not return patients. On a Thursday it's not unheard of to see 30 patients. On a Tuesday it's not unheard of to see 40 to 50 patients."

The faith-based, free clinic opens Tuesday and Thursday evenings to see patients like Angie from Lincoln who has been uninsured since 2002.

"As a matter of fact the last full time position I had for many years I had no health insurance with that job as well," Angie said. "Even though I was fully employed I had no insurance at all."

Angie has shopped for insurance in the individual market, but found it unaffordable.

"It's ridiculous. Even when I was working full time at a doctor's office making quite a nice salary I probably could not have afforded it. It's about as much as rent, so yeah, no way. Can't afford it. No."

Federal subsidies accessed through a health exchange are intended to make coverage more affordable. Subsidies will help pay for exchange plans on a sliding scale for families with incomes up to 4 times the poverty level, or about 88 thousand dollars a year for a family of four. An exchange would also be open to small businesses with up to 50 employees.

Jennifer Carter

Director of Public Policy, Nebraska Appleseed

If state lawmakers decide to create a Nebraska exchange, many new questions follow. How would people access it? The exchanges are meant to be virtual marketplaces online, but Jennifer Carter, Public Policy Director for the Nebraska Appleseed Center for Law in the Public Interest , says that might not be good enough.

"We have to be mindful that not everyone has broadband access, especially in Nebraska, Carter said. "You've got both urban and rural areas where that's not always available. So we also think that bricks and mortar, real places that people go and real people that people can talk to will be important."

Once people reach the exchange, who helps them find out what they qualify for and decide what to buy? Dennis Butler, who sells small-group insurance and is State Coordinator for the Nebraska Association of Health Underwriters, wonders if people will have the help they need to choose an appropriate plan.

"Are they going to choose the right one or are they just going to look at the column that says, how much does this baby cost?" Butler said. "Because that's an important issue to them, but cost isn't always the only issue. You have got to put people into the right peg."

Dennis Butler

Nebraska Association of Health Underwriters

Will plans in a Nebraska exchange cover more than what federal regulators require? The federal government pays for the first year of an exchange's operations cost. Can the state afford to pay after that? Many of these questions will be answered after lawmakers decide who is in charge. Carter envisions a governing board, independent from state government, with a lot of consumer input.

"And not just one consumer but, you know, a consumer who might represent low-income families, a consumer for folks with disabilities, a consumer for those people who are older who are all going to have slightly different barriers to engaging in this marketplace," Carter said.

Butler says exchange should be run by someone inside a state agency that already exists.

"Someone that an elected official, like the Governor, is responsible for," Butler said. "I think it should be inside the government with, say, an advisory board from other stakeholders."

Whoever ends up at the head of the exchange, most groups agree it is a decision that should be made by state lawmakers. Carter says if the state does not act, the federal government may act for them.

"I don't think it's so cookie cutter that what's going to work in New York is going to work in Nebraska," Carter said. "And this gives us a chance to deal with our rural urban issues in a way that would be more helpful."

States have until January 2013 to tell the federal government if they will design their own exchange and how they would do it. That deadline may be hard to meet. Governor Dave Heineman wants to wait until after the Supreme Court rules on the Affordable Care Act before deciding on a Nebraska exchange. But that ruling may not come until after the legislative session.

Back at Clinic with a Heart, Sue from Lincoln has another deadline in mind. She is waiting for her daughter to be seen for a sports physical. They have been uninsured for over a year and the insurance from her husband's new employer does not take effect until November. Sue says it has been a very tense year.

"There are a lot of times where, you know, you think maybe you have strep throat," Sue said. "And instead of going to the doctor you just gargle with salt water and cross your fingers. So, it's not where you want to be. It really isn't."



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