October 1, 2013, was a big day in U.S. history. That’s the date that, according to provisions of the 2010 Patient Protection and Affordable Care Act (the PPACA or ACA, more colloquially known as “Obamacare”), each state in the union was required to have launched an online marketplace, or “exchange,” through which residents can buy a health insurance policy.
The online exchanges are necessary to facilitate one of the most ambitious—and politically controversial—parts of the PPACA: the so-called “individual mandate,” the legal requirement that almost everyone legally allowed to reside in the U.S. must purchase health insurance.
The purpose is to compel the young and healthy, who make up a large portion of the uninsured, to buy insurance when they would otherwise probably choose not to. By doing so, they not only protect themselves from catastrophic costs in the event of an emergency, but also help reduce the cost of health care for everyone by increasing the number of people paying into the system. And it’s a lot of people. According to a 2012 report from the U.S. Department of Health and Human Services, around 38 percent of Americans without health insurance were young adults aged 19–34. That’s over 18 million people, and it’s in that population that we find many working artists, who, courtesy of the individual mandate, are now facing a new—and major—expenditure.
Not that it’s bad a thing, exactly. The PPACA provides substantial subsidies to help lower-income earners afford health care.
“Most artists are in the lower income range,” points out Renata Marinaro, the director of health services, eastern region, for the Actors Fund’s Artists Health Insurance Resource Center, which for more than a decade has sought to provide working artists with access to quality health care. “This is really going to benefit them.”
A little backstory: The U.S. is one of the only industrialized nations in the world that has not previously guaranteed health coverage to legal residents; 48.61 million Americans lacked health insurance at some point in 2011, ccording to the HHS survey. The consequences are expensive. Because the uninsured lack access to doctors for preventive care—and because hospitals are not legally allowed to turn away the very ill—costs of treating the uninsured are not only unnecessarily high (due to delayed treatments) but these costs also essentially get passed on to people with insurance, who absorb the price through increased premiums and co-pays. In fact, the U.S. spends far more on health care per person than other industrialized nations which offer universal health care. In 2011, according to figures from the Organization for Economic Co-operation and Development, the U.S. spent $8,508 per capita on health care, versus $5,600 for the Netherlands, the next highest spender, and more than double the OECD’s average of $3,339 per capita amongst industrialized nations.
Controlling the rise in health care costs is one of the main purposes of the PPACA. It seeks to accomplish this through a variety of means—such as improvements in information tracking and billing, treatment effectiveness testing, and preventing health insurance companies from denying coverage for pre-existing conditions—all of which are intended to help reduce the number of Americans who lack health insurance. But a core component of the act, and its most contested provision, is the individual mandate, which requires everyone to have health insurance or face a penalty to be leveled by the IRS.
In 2014, the first year this applies, the penalty will be relatively small: $95, or 1 percent of individual income, whichever is greater. By 2016, however, the penalty increases to $695, or 2.5 percent of income. Love the individual mandate or hate it (and many do—it was the subject of numerous legal challenges leading up to a 2012 decision from the U.S. Supreme Court that found the individual mandate constitutional), but there’s no avoiding it. The question, then, for working artists, along with everyone else affected by the PPACA, is how to navigate the system for purchasing health insurance, and how to decide what sort of health plan to buy.
Unfortunately, the process is anything but simple, in no small part due to the political opposition to the PPACA. With health insurance regulated at the state level, the PPACA creates a patchwork of different exchanges with different health plans implemented differently state by state—often according to the state government’s support of or opposition to the act. Although every state had the option to launch its own exchange, which would have given states considerable latitude to manage and regulate, 27 states chose not to, instead defaulting to a federally managed insurance exchange. (Seven other states rely on a partnership with the federal government to manage their exchanges.)
The first step in getting started is to visit HealthCare.gov, the federal clearinghouse for consumer information on the PPACA. The site contains links to all state exchanges and information on how to connect with local “navigators,” organizations throughout the country that have received federal grants to help connect people with health insurance in their state.
Unfortunately, access to navigators is affected by the same politics as the decision to set up state exchanges. The 16 states that developed their own exchanges—along with the District of Columbia—spend far more money on navigators than the 34 states that did not. According to an Aug. 14 report in the New York Times, the top spending state with its own exchange is New York, which will invest $27 million in combined state funds and federal grants toward connecting the uninsured with health plans. Texas, which tops the list of states with federally run exchanges, will be spending only $8.2 million, despite the fact that nearly 6.5 million more residents live there than in New York.
Either way, with so many people to connect with policies by Jan. 1, 2014, when individuals will become subject to fines (though due in part to problems with the rollout of the HealthCare.gov site, there is effectively a three-month grace period, with fines not taking effect until after Mar. 31), many nongovernmental organizations across the country are helping connect constituents with state-funded navigators, and arts organizations are no different.fund
One of the most proactive organizations I encountered researching this article was Springboard for the Arts, which supports economic and community development for the arts in St. Paul, Minn.
“There are more than 40,000 individual artists and nonprofit arts workers in Minnesota,” Nikki Hunt, the organization’s health program director, says. “Individual artists are twice as likely to be uninsured than the general population here, and the majority of arts organizations do not provide health care coverage to their employees.” Springboard for the Arts is working with Minnesota’s exchange, MNSure, to become certified navigators and in-person assisters who can directly support constituents in the sign-up process. This was a big component of its annual Artists’ Health Fair held this past Oct. 19 in Minneapolis.
The extent of Springboard’s involvement is somewhat exceptional. More typical of local arts organizations’ efforts are those by Artist Trust, a Seattle-based arts support organization, which has partnered with the mayor’s Office of Arts & Culture and other culture organizations, as well as theWashington Health Foundation, to provide a series of free public educational events that began last month. And Fractured Atlas, a national artist support and fiscal sponsorship organization, has likewise published a guide called “Obamacare and You,” educating its members on benefits, penalties, and subsidies.
Meanwhile, the Actors Fund, which has been a crucial resource in this arena for over a decade, since the program was initiated through an NEA grant to explore artists’ health care needs, will concentrate its efforts in New York and California. In New York, the Actors Fund will serve constituents as in-person assisters, and in California the Actors Fund will partner with Covered California, the California state exchange.
Working artists not lucky enough to have insurance through a union like Actors’ Equity, or membership organizations like Fractured Atlas or through other employment, face distinct challenges navigating the health plan purchasing process.
The cost basics for purchasing a plan are fairly simple to calculate. Subsidies in the form of a tax credit are available for anyone making up to four times the federal poverty level (roughly $46,000 a year for individuals). Part of the PPACA offered expanded Medicaid coverage, as well, another area affected by local political and budgetary concerns. As of the writing of this article, only 29 states have accepted or are moving toward accepting expanded Medicaid funding. Expanded funding raises the eligibility for Medicaid to 133 percent of the poverty level, or roughly $16,000 a year for individuals. Anyone making below that, who lives in a state with expanded Medicaid coverage, will be eligible for highly comprehensive, cost-free insurance.
Anyone making above that amount, up to the subsidy maximum, will be eligible for income-adjusted assistance. Based on your income, the government calculates the portion of your salary that should be allocated towards purchasing health care; the subsidy offered is calculated on a state-by-state basis against this individual or household contribution. Each exchange that follows the federal model categorizes plans by metal labellings: Platinum plans are the most expensive and comprehensive, followed by gold, silver, then bronze. An individual’s subsidy is calculated as the difference between their income-based contribution and the cost of the second-least-expensive silver plan available.
Say you’re a working artist making approximately $22,000. Based on your income, as an individual you’d be liable for a personal contribution of around $108 a month (according to an online estimator provided by the Kaiser Family Foundation). With a silver health care plan averaging nationally around $251 a month, you could receive a government tax credit subsidy of up to $113 a month to help purchase a plan. You can buy a more comprehensive gold plan and increase your personal contribution, or a less expensive plan with the same subsidy. These numbers will vary on a state-by-state basis, and you can specify your state of residence on the online estimator for a more accurate amount.
Figuring out your subsidy, though, can be tricky for working artists. “What’s generally unique to artists is that they are self-employed, or temporarily employed, or have part-time employment,” Marinaro of the Actors Fund told me. “Not only are they people who don’t typically get insurance through their employer, they also have variable income. So it’s going to be trickier for artists, for example, to document their income, for purposes of the subsidy, if, for instance, they haven’t filled out their 2013 tax returns yet.”
For the self-employed, most exchange questionnaires ask applicants to provide a previous month’s income to use as a baseline, but with uneven income over the course of a year, this can prove problematic. “They may low-ball it,” Marinaro told me, “thinking, ‘If I predict my income will be $22,000, then I’ll get a higher subsidy.’ But if they end up making more, they’re going to have to pay some of that subsidy back.”
But perhaps the biggest challenge for artists will be determining what services they need. The PPACA represents a massive perspective shift, compelling artists who previously lacked access to health care to sort out pricing and services with which they’ve had precious little experience. Artists have specialized health care needs. Dancers and musicians may have special joint and muscular issues due to repetitive stresses over their careers. Actors and singers may need special services for vocal injuries. Based on their current health conditions, artists may have been paying out-of-pocket for health services already, necessitating research to determine whether current providers accept certain plans on the exchange.
On the plus side, certain health plans may offer more generous benefits consumers should be aware of. Such details vary widely from state to state. In New York, for instance, some plans reimburse part or all of gym memberships, as a form of ongoing health maintenance.
The PPACA does, however, ensure certain baseline parameters. All eligible health plans nationwide offer a prescription drug benefit and include at least some birth control coverage. And while the PPACA protects individuals from being denied healthcare for pre-existing conditions, tobacco use can result in increased premiums for personally purchased plans, offering yet another incentive to quit smoking.
Despite its challenges, the PPACA, if it works as intended, will be a boon to artists, who, with improved health care, can enjoy longer, more productive careers. “The bottom line is the same for everybody,” Marinaro told me. “What’s the amount of medical risk you’re willing to accept? And what’s the amount of financial risk you are willing to take?”
Jeremy M. Barker is a performing arts critic and journalist based in Brooklyn.
