Panel Discussion on Women's Health
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2013 Women Leaders Conference
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Panel Discussion on Women's Health
- 1. Mental Health Carol I-PingTsao, MD, JD Associate Professor Department of Psychiatry & Behavioral Medicine Medical College of Wisconsin www.mcw.edu
- 2. Mental Health, Mental Stress & Mental Illness Stress Professional Maintaining Mental Management Treatment Health Techniques www.mcw.edu
- 3. Health Maintenance • Diet ( about 1800 cal/day) • Exercise (30 minutes 3-4x/week) • Sleep (8-10 hours/night) • Reduce/cease alcohol, caffeine, tobacco, illicit/licit drugs with abuse potential • Spend quality time (talking and playing - undivided attention) with spouse/significant other and children every day • Think quietly/meditate/pray every day www.mcw.edu
- 4. Mental Stress • Definition: Stress can be defined as the harmful physical and emotional responses that occur when external requirements outmatch individual capabilities and resources. • Stress precipitants can be negative or positive www.mcw.edu
- 5. Situational Factor(s) STRESS Individual Factor(s) www.mcw.edu
- 6. Stress And Illness • Short-lived, infrequent, milder episodes of stress pose little health risk • Sustained, high levels of stress can result in symptoms such as headache, upset stomach, difficulty concentrating, sleep disturbances, irritability and low morale • Increased risk for cardiovascular disease, musculoskeletal disorders, and depression www.mcw.edu
- 7. Two Forms of Coping • Problem-focused (Adaptive Coping) – Focus is on the problem – attempt to solve the problem, master the situation, or expand resources to deal with the situation. • Emotion-focused (Palliative Coping) – Focus is on managing the emotional response to a situation in order to attenuate the emotional impact. www.mcw.edu
- 8. Stress Management Techniques • Can control, reduce, sometimes even eliminate stress symptoms • These techniques are readily learned, can be individually tailored and improved upon by practice • Many draw from the theory and practice of cognitive and behavioral therapy www.mcw.edu
- 9. Easy-To-Do Stress Management Techniques • Deep breathing • Stretching • Mindful Awareness • Visual imagery • Thought stopping • Scheduling worrying • Positive affirmations www.mcw.edu
- 10. My Four Favorite Self Help Books • How to Talk So Kids Will Listen & Listen So Kids Will Talk by: Adele Faber and Elaine Mazlish (Feb 7, 2012) • Become a Better You by: Joel Osteen (Oct 15, 2007) • Women Food and God: An Unexpected Path to Almost Everything by Geneen Roth (Feb 8, 2011) • The Not So Big Life: Making Room for What Really Matters by: Sarah Susanka (Dec 26, 2007) www.mcw.edu
- 11. Mental Illness: Scope and Impact • Psychiatric disorders affect all ages, genders, and cultures • The vast majority of all illnesses and deaths in the world have behavioral components: – Heart disease – Obesity – Addiction – Infectious disease • Psychiatric disorders are the: – #2 cause of disability in the world – #1 cause of disability in economically established countries www.mcw.edu
- 12. Mental and Physical Illness • 1 in 2 physically ill persons have a coexisting mental illness/addiction • Depression co-occurs in: – 33% people who have had a heart attack – 40% people with cancer – 50% people who have had a stroke www.mcw.edu
- 13. Mental Health Treatment • Depressive disorders • Bipolar disorder • Anxiety disorders • Substance Abuse • Psychotic disorders • Sexual dysfunctions • Eating disorders • Childhood disorders • Trauma disorders • Chronic pain • Attention deficit • Personality disorders disorders • Others • Dementias www.mcw.edu
- 14. Affordable Care Act • In 2014, health insurance plans must cover mental health and addiction services as part of the essential benefits • Mental Health Parity and Addictions Equity Act of 2008 required insurance coverage for mental health and addictions be equal to coverage of other illnesses. • Studies have shown that every dollar spent on mental health care results in a savings of $12. www.mcw.edu
- 15. How Employers Can Help • Talk openly about mental diseases in public forums – especially the major ones for employers (stress/anxiety, depression, substance abuse) • Provide mental health benefits including Employee Assistance Programs and access to external referrals • Maintain confidentiality www.mcw.edu
- 16. Employee Assistance Programs • Complete a thorough assessment of their organizational culture • Suggest (even incentivize) employees complete anonymous health risk assessment • Tailor programs targeting the areas of greatest need (likely stress, depression, obesity, substance abuse) www.mcw.edu
- 17. Employer Benefits • Employers who provide mental health benefits have lower incidents of job burnout, workplace injury, and onsite violence www.mcw.edu
- 18. Preventing Job-Related Stress • Ensure work type and work volume is in line with employee capabilities and resources • Design jobs to provide meaning, stimulation, and opportunities for employees to use and develop their skills • Clearly define employees‟ roles and responsibilities www.mcw.edu
- 19. (Continued) • Provide opportunities for employees to participate in decision making that affects their jobs • Clear, consistent communication • Provide opportunities for social interaction among employees • Establish work schedules that are compatible with responsibilities outside the job www.mcw.edu
- 20. Summary • Practice health maintenance • When stress increases, choose one technique – commit to using it daily • Read (and apply) a pertinent self-help book • If symptoms (such as interpersonal irritability, withdrawal from activities, physical fatigue, etc…) worsen, seek professional care www.mcw.edu
- 21. THANK YOU QUESTIONS? Carol I-Ping Tsao, MD, JD Medical College of Wisconsin Associate Professor of Psychiatry and Behavioral Medicine ctsao@mcw.edu www.mcw.edu
- 22. Taking Charge of your Fertility Options for Delaying Parenthood Sabina Diehr, MD Associate Professor Department of Family & Community Medicine Medical College of Wisconsin www.mcw.edu
- 23. Declining # of Children / Couple www.mcw.edu
- 24. www.mcw.edu
- 25. www.mcw.edu
- 26. Aging and Fertility in Women www.mcw.edu
- 27. Women are born with ALL of their eggs www.mcw.edu
- 28. Men are able to make fresh sperm daily www.mcw.edu
- 29. Infertility Treatments www.mcw.edu
- 30. % of Egg Transfers Resulting in Live Births www.mcw.edu
- 31. What is Important to YOU? • Duration • Efficacy • Convenience • Not “messy” • Also helps acne, or menstrual flow • Little to no side-effects • No medical contraindications www.mcw.edu
- 32. Contraceptive Choices www.mcw.edu
- 33. Barrier Methods – Condoms – Diaphragm – Today‟s Sponge www.mcw.edu
- 34. Short-Acting Reversible – Pill – Patch – Nuva Ring www.mcw.edu
- 35. Long-Acting Reversible – Depo-Provera – IUD – Implanon www.mcw.edu
- 36. Non-Reversible – Tubal ligation – Vasectomy www.mcw.edu
- 37. Natural Family Planning www.mcw.edu
- 38. Failure Rates of Contraceptives Typical Use Perfect Use NFP / Withdrawal 18.4% 5% Condom 15% 5% Pill, Patch, Ring 8% 0.3% Depo-Provera Shot 6.7% 0.3% IUD 0.2% 0.2% Implanon 0.05% 0.05% www.mcw.edu
- 39. www.mcw.edu
- 40. Questions? Thank you! www.mcw.edu
- 41. Navigating the Changing Health Care System: Tips for Business and Personal Planning Sheila G Moore, MD, FACR Professor and Chief, Pediatric Imaging Medical College of Wisconsin www.mcw.edu
- 42. Early Healthcare in the US • Barbers and Physicks • First Reform: 1854 Bill for the Benefit of the Indigent Insane • Freedman‟s Hospitals • The New Deal www.mcw.edu
- 43. Medicare and the Expansion of Health Insurance • 1920‟s: Dallas teachers have first employer sponsored health care. Blue Cross is established • WWII: Employer Health Insurance offered to offset freeze in wages • 1965 Lyndon Johnson Signs Medicare Legislation www.mcw.edu
- 44. Financial Impact of Health Care www.mcw.edu
- 45. 2010 Affordable Care Act (ACA) • Quality, Affordable Health Care for All – No pre-existing exclusion – State Health Insurance Exchanges/ Lower rates – Children Covered to 26 – No Maximum Lifetime/ Annual Benefit • Enhanced Enrollment Public Programs – Medicaid open to all low income individuals • Improving Quality and Efficiency of Health Care – The “Medicare Provision” – Will “save” $450B in Medicare costs www.mcw.edu
- 46. Provisions of the ACA • Prevention • National Healthcare Workforce Commission • Fraud and Abuse • Pharmaceutical Reform • Long Term Care • Revenue Provisions • Manager‟s Amendment www.mcw.edu
- 47. 2010 Implementation • Ban on lifetime limits on benefits • Dependent coverage until age 26 www.mcw.edu
- 48. Act II: 2014 • Tax Credits For Health Insurance Premiums – “Middle Class” Benefit – Can be applied to Premium Payments monthly (Advanceable) – Income between 100% and 400% of the poverty line who are not eligible for other affordable coverage • In 2013 400% of Poverty line for family of 4 is $92,200. • In 2013 400% of Poverty line for an individual is $44,680 www.mcw.edu
- 49. ACT II: 2014 • Required State “Health Insurance Marketplace” • Individual Mandate – Workplace – Individual/Health Insurance Marketplace – Pay a fine • Estimated 6M Affected • Average fine $1200/person „16 • Expected to raise $6.9B 2016 • Earn Less than 133% of poverty level eligible for Medicaid www.mcw.edu
- 50. Implementation: 2014 • Reforms slated to start in 2014 • Ban on Exclusion for Preexisting apply to plans both inside and outside Condition: Insurers cannot exclude or limit the exchange coverage for people with preexisting health • Guaranteed Coverage: Requires problems insurers to accept every individual • Essential Health Benefits: Requires and employer that applies for insurers to cover a comprehensive set of coverage health benefits. • Ban on Waiting Periods: Employers • Out-of-Pocket Cost Limit: Holds out-of- cannot impose waiting periods longer pocket costs to the level established for than 90 days before an employee can high-deductible health plans that qualify for be eligible for coverage health savings accounts • Rating Requirements: Insurers are • Actuarial Value: Requires insurers to restricted from using health status, gender, and other such factors in cover at least 60 percent of total costs setting premiums under each plan and sell plans that meet new benefit tiers based on average costs covered. www.mcw.edu
- 51. Effect on Small Business: Self Employed • Self Employed • Individual Shared – Jan 2014: Individual Provision Shared Responsibility – Essential Coverage Provision – Qualify for Exemption • Less than 25 Employees – Pay When Filing Taxes • 25-50 Employees • Individual Insurance • >50 Employees Marketplace • Medicaid Expansion www.mcw.edu
- 52. Effect on Small Business www.mcw.edu
- 53. Effect on Large Business/Corporations www.mcw.edu
- 54. Wisconsin • Under ACA: Regulation falls to the states • 11 States and DC have passed laws to implement ACA • Connecticut (7), California (6) At least one: Arkansas, Maine, Maryland, New York, Oregon, Rhode Island, Utah, Vermont, Washington, District of Columbia • Result: 2013 will be a critical time in State Legislatures to pass the bills needed www.mcw.edu
- 55. Impact On Personal Taxes: 2013 • Medical Hospital Insurance (Part • Limit on Flexible Spending A) Tax Account: $2500 per year • Medicare Payroll Tax of – Previously $5000 2.35% on earnings • Cadillac Health Insurance >$200/$250K – 40 % Penalty for being • Imposed to keep Medicare enrolled in a high-cost funded insurance plan • Unearned Income Tax – $10,200 (I) and $27,500 (F) • Dividends/Rent/Interest • 3.8 % Surtax on Incomes more than $200K/$250K www.mcw.edu
- 56. Conclusion • 2010 Implementation is here • Business • 2013 Tax Consequences are – Learn the provisions here – Plan for implementation – Educate employees • 2014 Implementation is – Plan recruitment/retention – Sweeping – Partner with Government, – Here Providers and Payers – Expensive • You and Your Family – Plan for implementation – Goal: Quality and Access – Educate yourselves – Greater care for less – Be healthy www.mcw.edu
- 57. Thank You! QUESTIONS? Sheila G. Moore, MD, FACR Children‟s Hospital of Wisconsin Professor and Chief of Pediatric Radiology Medical College of Wisconsin smoore@chw.org www.mcw.edu
- 58. References • Commonwealth Fund (2013, • http://www.sba.gov/content/sel February 1). U.S. f-employed Healthcare: State action on Affordable Care • http://www.sba.gov/content/e • http://www.healthcare.gov/l mployers-with-50-or-more- aw/timeline/index.html#eve employees nt41-pane • H.R. 4872, Reconciliation Act • http://www.sba.gov/content/ of 2010 (Final Health Care employers-with-fewer-50- Legislation: Analysis by the employees Congressional Budget • http://www.sba.gov/content/ Office; March 20 , 2010 employers-with-fewer-25- employees www.mcw.edu
Hinweis der Redaktion
- Wait up to a year for donor eggs. women younger than 35, the percentage of live births per cycle is 39.6%.For women ages 35 to 37, the percentage of live births per cycle is 30.5%.For women ages 38 to 40, the percentage of live births per cycle is 20.9%.For women ages 41 to 42, the percentage of live births per cycle is 11.5%.For women ages 43, the percentage of live births per cycle is 6.2%.After age 44, little more than 1% of IVF cycles with non-donor eggs lead to live birth.As you can see, IVF success goes down significantly after age 40. For this reason, most women 40 and up use donor eggs.Success rates when using donor eggs are not as dependent on the woman's age.The percentage of live births per cycle when using donor eggs is 55.1% with fresh embryos.The percentage of live births per cycle when using donor eggs is 31.9% when using frozen embryos.It's interesting to note that IVF success rates with donor eggs are even higher than a woman younger than 35 using her own eggs. Donor eggs offer the best chance for success.SART (society for Assisted Reproductive Technology)Top of FormBottom of FormTotal Cycles:154412Treatment TypeIVF>99%GIFT<1%ZIFT<1% Procedure FrequencyICSI66%Unstipulated1%PGD5% Diagnosis FrequencyTubal Factor6%Male Factor17%Ovulatory Dysfunction7%Other Factor8%Diminished Ovarian Reserve16%Unknown Factor12%Endometriosis4%Multiple Female Factor11%Uterine Factor1%Female and Male Factor18%Fresh Embryos From Non-Donor Oocytes <3535-3738-4041-42>42Number of cycles397211993020130102776033Percentage of cycles resulting in pregnancies46.238.529.319.59.1Percentage of cycles resulting in live births40.131.921.612.24.2Reliability Range(39.7 - 40.6)(31.2 - 32.5)(21.0 - 22.2)(11.5 - 12.8)(3.7 - 4.7)Percentage of retrievals resulting in live births42.935.224.814.55.3Percentage of transfers resulting in live births46.338.427.516.66.5Percentage of cycles with elective single embryo transfer11.76.51.90.60.5Percentage of cancellations6.49.512.716.320.7Implantation Rate36.027.317.59.44.0Average number of embryos transferred1.92.12.53.03.1Percentage of live births with twins30.826.721.114.910.6Percentage of live births with triplets or more1.21.31.30.70Thawed Embryos From Non-Donor Oocytes <3535-3738-4041-42>42Number of Transfers134806665495617811284Percentage of transfers resulting in live births39.335.730.324.516.5Average number of embryos transferred1.91.81.92.02.1Donor Oocytes (all ages) Thawed EmbryosFresh EmbryosNumber of Transfers66419332Percentage of transfers resulting in live births35.754.9Average number of embryos transferred1.91.9Caution: Patient characteristics vary among programs; therefore, these data should not be used for comparing clinics.Select Treatment Type:Select to filter numbers on this report based on your treatment type selection.Select DiagnosisSelect to filter numbers on this report based on your diagnosis selection.Select YearSelect the year for which you would like to view data. Cycle data are reported by Start Date, January 1 to December 31 of each year. Years shown in this drop-down list are those that are available.IVF Treatment TypePercentage of fresh, non-donor cycles that utilize In Vitro Fertilization (IVF). IVF involves retrieval of eggs from the ovaries with subsequent exposure to sperm in the laboratory and subsequent transfer of fertilized eggs / embryos to the uterus.GIFT Treatment TypePercentage of fresh, non-donor cycles that utilize Gamete Intrafallopian Transfer (GIFT). GIFT involves retrieval of eggs from the ovaries with subsequent placement of unfertilized eggs and sperm into the fallopian tube. This is typically done as laparoscopy (surgical procedure).ZIFT Treatment TypePercentage of fresh, non-donor cycles that utilize Zygote Intrafallopian Transfer (ZIFT). ZIFT involves retrieval of eggs from the ovaries with subsequent exposure to sperm in the laboratory and subsequent transfer of fertilized eggs / embryos to the fallopian tube. This is typically done as laparoscopy (surgical procedure).ICSI Procedure FrequencyPercentage of fresh, non-donor cycles in which ICSI was performed (excluding Second Day ICSI). ICSI is Intracytoplasmic sperm injection. This is where a single sperm is directly inserted into a single egg by the embryologist in hopes of achieving fertilization.Unstipulated Procedure FrequencyPercentage of fresh, non-donor cycles in which the patient was not medicated to produce follicular development. No oral or injectable medications were given to stimulate the ovaries. This is commonly referred to as natural cycle IVF.PGD Procedure FrequencyPercentage of fresh, non-donor cycles where Preimplantation Genetic Diagnosis was used on some or all embryos. PGD includes screening for chromosomal aneuploidy (too many or too few chromosomes in an embryo), translocation abnormalities (unbalanced number of chromosomes) or specific genetic diseases.Tubal Factor Diagnosis FrequencyInfertility resulting from absence, blockage or disease of the fallopian tubes in fresh, non-donor cycles.Ovulatory Dysfunction Diagnosis FrequencyInfertility resulting from disorders of ovulation (failure to release eggs) in fresh, non-donor cycles.Diminished Ovarian Reserve Diagnosis FrequencyInfertility resulting from decreased egg numbers in fresh, non-donor cycles.Endometriosis Diagnosis FrequencyInfertility resulting from the abnormal presence of uterine lining tissue outside of the uterus in fresh, non-donor cycles.Uterine Factor Diagnosis FrequencyInfertility associated with diseases or abnormalities of the uterus in fresh, non-donor cycles.Male Factor Diagnosis FrequencyInfertility caused by problems with sperm in fresh, non-donor cycles. This includes decreased sperm numbers or absence of sperm. This also would include problems with sperm movement (motility) or function.Other Factor Diagnosis FrequencyInfertility associated with other identifiable problems not specifically listed in fresh, non-donor cycles.Unknown Factor Diagnosis FrequencyInfertility for which no cause (male or female) is determined despite a thorough evaluation of both partners in fresh, non-donor cycles.Female Only Diagnosis FrequencyInfertility associated with more than one problem in fresh, non-donor cycles where all identified problems are female.Female and Male Diagnosis FrequencyInfertility caused by both male and female issues in fresh, non-donor cyclesTotal CyclesThe total number of cycles initiated by this clinic in the year selected. This number includes cycles that are excluded in various statistics below and can be cycles designated as experimental, cancelled cycles, cycles without potential for outcome such as embryo banking, etc.Fresh Embryos From Non-Donor Oocytes by AgeThis section shows statistics, of fresh, non-donor (patient's own eggs) cycles by female age group.Number of CyclesNumber of cycles initiated in each age group.Percentage of Cycles Resulting in PregnanciesThis is the percentage of fresh, non-donor cycles where a transfer occurred and the treatment outcome was a clinical intrauterine pregnancy (documented by ultrasound). This does not always result in a live birth. Some of these pregnancies result in a miscarriage or a voluntary termination of a pregnancy.Percentage of Cycles Resulting in Live BirthsThis is the percentage of fresh, non-donor cycles where at least 1 live birth occurred by female age group. A live birth is counted when at least one fetus was live born, i.e. showed signs of life after the complete expulsion or extraction from its mother; generally, when a birth certificate is filed.Reliability RangeThis is a statistical term that accounts for the fact that any single number derived from a group average has a range of probability of being accurate. Larger groups yield more narrow ranges because there is more data and smaller groups are subject to more variability. The ranges in these brackets describe a 95% level of confidence for transfer to live birth rate.Percentage of Retrievals Resulting in Live BirthsThis is the percentage of fresh, non-donor cycles that reached retrieval (cancelation did not occur) where at least 1 live birth occurred.Percentage of Transfers Resulting in Live BirthsThis is the percentage of fresh, non-donor cycles that reached transfer where at least 1 live birth occurred by female age group.Percentage of Cycles with Elective Single Embryo TransferThis is the percentage of fresh, non-donor cycles that reached transfer where exactly 1 embryo was reported being transferred while the number of cryopreserved embryos was greater than 0 by female age group.Percentage of CancellationsThis is the percentage of fresh, non-donor cycles that were reported as cancelled (did not reach retrieval) by female age group.Implantation RateThis is the greater of either the fetal hearts reported on ultrasound or the number of live born plus still born over the total number of embryos transferred for fresh, non-donor cycles by female age group.Average number of Embryos TransferredThis is the average number of embryos transferred in cycles with a transfer for fresh, non-donor cycles only by age group at cycle start.Percentage of Live Births with TwinsThis is the percentage of fresh, non-donor cycles where at least 1 live birth occurred and where that result was twins by female age group.Percentage of Live Births with Triplets or MoreThis is the percentage of fresh, non-donor cycles where at least 1 live birth occurred and where that result was triplets or more by female age group.Thawed Embryos From Non-Donor OocytesCycles using thawed embryos from non-donor oocytes by female age group.Number of TransfersThis is the number of cycles using thawed embryos from non-donor oocytes with a transfer by female age group.Percentage of Transfers Resulting in Live BirthsThis is the percentage of cycles using thawed embryos from non-donor oocytes that reached transfer where at least 1 live birth occurred by female age group.Average Number of Embryos TransferredIn cycles that reached transfer using thawed embryos from non-donor oocytes, this is the average number of embryos transferred by female age group.Donor Oocytes (All Ages) | Fresh Embryos | Thawed EmbryosThis section shows cycles using donor oocytes separated by fresh and thawed.Number of TransfersBy embryo state (fresh/thawed), this is the number of cycles using donor oocytes that reached transfer.Percentage of Transfers Resulting in Live BirthsBy embryo state (fresh/thawed), this is the percentage of cycles using donor oocytes that reached transfer where at least 1 live birth occurred.Average Number of Embryos TransferredBy embryo state (fresh/thawed), in cycles that reached transfer using donor oocytes, this is the average number of embryos transferred.© Copyright 2013 SART, All Rights Reserved.
- 49 % of all pregnancies in the US are unintended= 6.7 Million unintended pregnancies /year43% of these are terminatedDuration & reversibilityReversibility : Short & long-termEfficacyConvenienceAffordabilityEffect of bleedingFrequency of side effectsProtection against STDsMedical Contraindications: need to quit smoking… r
- Contraception is important:49% of pregnancies in the US are unintended= 6.7 Million/ year>> 43% of unintended pregnancies are terminated =
- Depo: IUD: Mirena 5 years, 52mg hormone - secrets 20 micrograms daily; irregular but lighter bleeding in 98%. Improved endometriosis and fibroidsCopper 10 years. Heavy bleeding can occur - effect weans off. High initial cost. Small risk of uterine perforation, effective for emergency contraception up to 5 days after unprotected intercourse. Implant: 3 years, 4 cm x 2 mm flexible rod containing 68 mg of hormone; suppresses ovulation, thickens cervical mucous. 11% discontinue because of irregular bleeding. Improves acne and painful periods.
- Sterilization regret ( US cohort study) 20% in women under 30; 6% in women over 30
- Mention Emergency Contraception (including IUD)
- We have come a long way since this lovely CaveFamily
- Upheld by US Supreme Court June 28, 2012; 10 Titles. Title Synopsis from E. McDonough, DPh, MPA Professor of Health Policy and Management; Harvard University School of Public Health; Boston
- Graph taken from John E McDonough; Health Stew; taken from March 10,2010 from the ACA Analysis of the Congressional Budget office
- A terrible accident on a theater stage changed her life forever. But an Ellsworth, Wisconsin woman never lost sight of her dreams. Tasha Schuh is back in the spotlight again, with a national title. She's just been named Ms. Wheelchair USA.Read more: Wisconsin woman named Ms. Wheelchair USA - KMSP-TVhttp://www.myfoxtwincities.com/story/19135361/wisconsin-woman-named-ms-wheelchair-usa#ixzz2JmR4S3Ic
- Fine for not having insurance in 2014: $600 Starting in 2014 if your employer doesn’t offer insurance, you will be able to buy it directly in the Health Insurance Marketplace. Individuals and small businesses can buy affordable and qualified health benefit plans in this new transparent and competitive insurance marketplace. The Marketplace will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through the Marketplace, and you will be able buy your insurance through Marketplace too.2. Under the new law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she will be eligible for an exemption3. Under the new law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she will be eligible for an exemption 4. Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years.