Editor's Note: It's been three years since the Patient Protection and Affordable Care Act was signed into law by President Obama. At first, the term "Obamacare" was used as a pejorative by opponents of the most sweeping overhaul of the American health care system since the passage of Medicaid and Medicare in 1965.
The President later embraced the term, now widely used to describe legislation that will take at least a decade to fully implement, with uncertainty and continued debate along the way. Some measures have already taken effect, while others are still years away. But 2014 will be a watershed year, when many of the most controversial and significant aspects of the law are scheduled to kick in.
Our series takes stock of Obamacare in New Hampshire by looking at provisions of the law already in place, what lies ahead in 2014 and implications as the law takes full effect in the last five years of the decade, assuming efforts to have it repealed or defunded do not succeed.
Beginning Jan. 1, nearly everyone will be required to have health insurance.
People will satisfy that mandate if: they have health insurance through their employer; or purchased an individual or family plan through a broker; or are on Medicaid or Medicare; or are a child enrolled in the Children Health Insurance Program; or have TRICARE for service members and their families; or are on the veterans health program.
Some people are exempt from the mandate: Indian tribe members, illegal immigrants, inmates, those religiously opposed, those who do not earn enough to pay federal income tax ($10,000 for an individual, $20,000 for a family) or those whose health insurance would exceed 8 percent of income.
The law will be enforced by the Internal Revenue Service through income tax filings. For 2014, the fine for not having insurance will be $95 for an adult and $37.50 per child, with a $285 family cap or 1 percent of income.
The fines will increase substantially in both 2015 and 2016.
If an individual or family does not have health insurance, they can purchase coverage through the NH Marketplace, or electronic exchange, which begins operating Oct. 1, though plans won't take effect until Jan. 1.
The federal government will run the exchange, which will allow residents to compare plans offered by the one company qualified for the exchange in New Hampshire: Anthem Blue Cross Blue Shield.
The exchange will have federally hired and trained "navigators'' to help people compare policies and determine whether they qualify for a federal premium subsidy or Medicaid benefits, if state lawmakers decide to expand eligibility for adults.
Insurance coverage can also be purchased directly from companies selling health insurance in the state, such as Anthem, Harvard Pilgrim, Cigna and several others.
Also, some local insurance agents sell health insurance plans.
Public remains uninformed
Tricia Brooks knows a thing or two about helping an uninformed public learn about new health care options. A senior fellow at the Center for Children and Families at Georgetown University and the founding CEO of the state's health insurance program for children, she told a legislative hearing in May that people are remarkably unaware of the new health care landscape being shaped by Obamacare.
"There is extremely limited awareness of what's coming," she told the Joint Health Care Reform Oversight Committee at the State House in Concord. "We think it's all over the media, but surveys show that three-quarters of the people who are going to be helped with coverage options under health care reform don't know what's coming."
That may be in large part because so few New Hampshire residents have been directly affected by the changes that have taken place so far as a result of the Affordable Care Act.
The most widely known provision of the law that took effect shortly after it was enacted in 2010 requires health insurance companies to allow adults to keep dependents on their policy until age 26, as opposed to 18. New Hampshire has had such a requirement in state law since 2007, but Obamacare added a new twist.
"We had a similar provision in New Hampshire law, but it didn't help everyone," said Lisa Kaplan Howe, policy director at New Hampshire Voices for Health. "If you were a young person whose parents lived in New Hampshire but worked for a large company that bought insurance outside of New Hampshire, or if you worked for a large employer who was self-insured, it did not benefit you. There was a large group of young adults who were left out. And now it's national until age 26."
The other provision that is fairly well-known and already in effect bans health insurance companies from denying coverage because of pre-existing medical conditions for children under the age of 19. The ban goes into effect for adults in 2014.
"The year 2014 has become the focal year that people think about, and a lot of people think nothing has happened yet, but the idea has been all along to roll this thing out in stages," Howe said.
Benefits now, savings later
That's a big part of the problem with Obamacare, according to Bob Nash, president of the N.H. Association of Insurance Agents. Many of the benefits come early, but the expansion of the insurance pool to help cover the costs doesn't come until later.
"You get the immediate benefits, but the savings have been postponed by 10 years," he said. "With these enhanced benefits and other essential criteria in the law, they have mandated loads of additional coverage, so what's bound to change? The premiums."
Nash said the most widely felt impact of Obamacare so far has been an increase in health insurance premiums, some of which occurred immediately after the law was passed. And that was just the beginning.
"I've heard estimates from 10 percent to 400 percent premium increases moving forward," he said. "Some people are suggesting that there will be such rate shock that it's going to throw the entire situation into turmoil."
Other requirements of Obamacare that are already in place and possibly affecting premiums include:
-- Insurers are now prohibited from imposing lifetime dollar limits on essential benefits, such as hospital stays, on newly issued policies.
-- All new insurance plans must cover preventive care and medical screenings as defined in the law, including such things as colonoscopies and annual checkups, without charging a deductible, co-pay or coinsurance.
-- Insurers are prohibited from dropping policyholders when they get sick. "A lot of those benefits have already gone into effect, and the premiums actually haven't gone up as steeply as they had in prior years," Howe said.
"It's important for people to keep in mind that health insurance premiums have been going up double digits, at three to four times the rate of inflation, for years," she said. "I don't think anyone expects the ACA or any law could take that sharp increase and make it a decrease. Our hope is to take that sharp increase, level it off, and hopefully get to the point where it mirrors the consumer price index instead of being multiple proportions above it."
Impact on premiums
One of the changes that has taken effect with a positive impact on premiums is the so-called "medical loss ratio" provision. "It's a really wonky term," Howe said. "But the intent of the provision is to make sure insurance companies are spending the majority of premium dollars on health care, not salaries, bonuses, marketing or other administrative expenses."
Insurance companies have to document that they spent at least 80 to 85 percent of the premiums collected on health care services for policyholders, or issue refund checks.
"Not many people in New Hampshire got those refund checks," Howe said. "That means the law is doing what's intended, and insurance companies are adapting their ways to meet those targets."
The state Insurance Department commissioned a study by Gorman Actuarial of Marlborough, Mass., which specializes in health insurance analysis.
The report, delivered last September, predicted the impact on premiums will vary, depending on a person's age, economic status and health. About a third of the population will see no significant change. Rates will go down for the population with the lowest income and the most significant health care needs. And one-third of the population will see significant rate increases, mostly younger, healthier individuals with higher-than-average incomes.
The last major aspect of the law to take effect this year will be the launch of state-by-state online marketplaces or exchanges for health insurance in October. In theory, the Health Insurance Marketplace is supposed to offer the kind of online, comparison shopping consumers have become familiar with when purchasing everything from auto insurance to airplane tickets.
But most of the companies that sell health insurance in New Hampshire are standing on the sidelines for now. Anthem is the only company that will be offering plans on the marketplace when it launches, and according to company spokesman Christopher Dugan, details about those plans won't be available until early September.
"We will be going out with significant member education materials at that time," he said. "The plans are currently in the review and approval stage; it's a bit early to talk about specifics."
email@example.com; Staff reporter Garry Rayno contributed to this article.