After all the dust settles and democracy returns to sanity, many of us will still be left with a big question: What really is all this health care fuss about anyway, and what does it really mean for all of us? Words can be a trigger for all sorts of crazy emotions, but whether you call it “Obamacare” or “health care reform” doesn’t really matter, because the only real cure is accurate information.
Regardless of what nickname you use, Obamacare and health care reform are the same thing: The Patient Protection and Affordable Care Act (PPACA). And more importantly, they are the law. The House of Representatives and Senate passed the PPACA, and the President of the United States signed it into law on March 23, 2010. The Supreme Court of the United States upheld the constitutionality of the PPACA on June 28, 2012. By any accounting, the law is the biggest overhaul of the nation’s healthcare system since the passage of Medicaid and Medicare in 1965.
With all the politics and ongoing public debate, we shouldn’t be too surprised that people are a little confused. The law itself is more than 950 pages long, covers everything from “Immediate Improvements in Health Care Coverage for All Americans” to “Supporting the Existing Health Care Workforce” and reads mostly like this, “Section 2735 of the Public Health Services Act (42 U.S.C. 300gg-21), as so redesignated by section 1001 (4), is amended—by striking subsection (a); …” and so on. That’s a lot of pretty obscure information to capture on a bumper sticker, or in a five-second sound bite on the evening news. It reminds me of the Farm Bill…but that’s a blog for another day. Let’s stay focused on health care reform.
I am not an expert on health care, and I confess, I did not read the 950-plus-page document myself. But I have a good friend who did (and is an expert), and what follows is his explanation. Our goal is to help make things a little clearer, so here is an overview of what we think are the most important features of the law, and the ones that will probably have the most direct effect on you and your family.
1. Let’s start with access to healthcare coverage. Under the Law:
- Adult children can stay on their parents’ health care plans up to age 26.
- People cannot be denied coverage and cannot be charged more for their coverage, because they have a preexisting condition.
- Women cannot be charged more than men for their healthcare coverage.
- Coverage cannot be rescinded or taken away due to illness or a serious health condition.
2. The quality of health care coverage is also standardized so that consumers will be assured that their coverage includes something called “essential health benefits.” The PPACA ensures that all health care plans sold in the individual or small group markets, either inside or outside the new “exchanges,” provide coverage within at least the following 10 categories:
- Ambulatory patient services;
- Emergency services;
- Maternity and newborn care;
- Mental health and substance abuse disorder services, including behavioral health treatment;
- Prescription drugs;
- Rehabilitative and habilitative services and devices;
- Laboratory services;
- Preventive and wellness services and chronic disease management;
- Pediatric services, including oral and vision care.
3. In addition to essential health benefits, the PPACA also requires that most health plans provide first-dollar coverage for prevention and wellness services.
- For example, most plans have to cover the following types of services at no cost: screenings for high blood pressure, cholesterol, type-2 diabetes, colorectal cancer (for adults 50+), as well as immunizations for hepatitis A and B, shingles, HPV (Human Papillomavirus, a cause of cervical cancer in women), and the flu.
- Prevention and wellness service for women include screenings for anemia, breast and cervical cancer, domestic violence, gestational diabetes, hepatitis B, HIV, HPV, and osteoporosis.
- And for children, screenings for autism, high blood pressure, depression, developmental issues, hearing, obesity, blood disorders, HIV, vision, and all recommended vaccinations.
4. Along with essential health benefits and first dollar coverage of prevention and wellness services, the PPACA also includes the “minimum coverage provision,” better known as the “individual mandate.” In order to provide expanded coverage for all Americans, it is important that as many of us as possible, both the healthy and not-so-healthy, obtain coverage. The Individual Mandate moves us toward that goal by requiring that almost all U.S. citizens and legal residents obtain and maintain coverage for themselves and their families, or pay a penalty.
- The penalty is fairly light when the PPACA goes into effect on January 1, 2014. In the first year, the penalty for not having coverage will be $95 per adult, $47.50 per child, and up to $285 per family or 1 percent of household income, whichever is greater.
- These penalties build quickly, so that by 2016 they are $695 per adult, $347 per child, and up to $2,085 per family or 2.5 percent of household income, whichever is greater.
- The PPACA takes a few important steps that could take the edge off of requiring people to have insurance. First, someone who already has insurance from sources like Medicare, his or her employer (or spouse’s), or another program do not need to change his or her plan.
- Starting in 2015, employers with 50 or more employees will be required to provide coverage to their employees or pay a penalty.
- For low-income adults, the Law gives states the option of expanding Medicaid coverage to adults earning up to 138 percent of the Federal Poverty Level, and offers these states 100 percent matching funds to cover expansion for 2014 through 2016. For later years, the federal match then decreases down to 90 percent for 2020 and beyond. Roughly 30 governors support expansion, and an additional 6 are weighing the options.
5. For people who need to purchase insurance on their own, the PPACA establishes virtual health care marketplaces, or exchanges, where people and small businesses can shop for health care coverage online. The exchanges enable people to shop for care by comparing plans based on cost, benefits, provider (physician) networks, and eventually, on the quality of care each plan provides.
- While shopping on the exchange, individuals and families can also determine if they are eligible for insurance subsidies in the form of federal tax credits.
- Families with incomes between 100 percent and 400 percent of the Federal Poverty Level who purchase insurance on the Exchange are eligible for a subsidy. You can go to healthreform.kff.org/subsidycalculator.aspx to determine if you are eligible for a subsidy, and for how much.
The changes included in the PPACA are expansive, and they touch almost every aspect of the nation’s healthcare system. Uncertainty and fear are a natural and expected part of any change of this magnitude. The law is not yet fully implemented, and although we are starting to get some indications, we still don’t know what will happen to the cost of premiums or what effect shopping for coverage in the online marketplaces will have on the types and cost of coverage offered there. We don’t know what the nation’s medium-size and large employers will do to help manage cost in the PPACA. Will they drop coverage, pay the penalty, and put employees into the exchanges? Will they reduce hours, shifting employees from full- to part-time status in order to drop them from coverage without penalty?
As a large employer myself (we have almost 900 employees), this law encourages us to help our employees even more to lead healthier lives and prevent health problems in the first place. (Gee, that sounds like something my grandfather thought of more than 60 years ago. Back then, the government and medical establishment scoffed that people’s behaviors could prevent disease. Well, it took them long enough to figure it out, but now we the people have to help the government change its behavior.) But as an employer I also know that when just one person gets truly sick, everyone’s healthcare costs goes up. It’s the same thing for the country. There is only one true way for all of us to have cheap and affordable health care, and that’s to help each and every one of us stay as healthy as possible.
But here’s another important thing to remember: we can all do everything we can to stay healthy, but things still happen. People who do everything right can still get cancer. Cautious people can still fall off ladders or become injured through no fault of their own. That’s why it’s so important to look out for each other, and make sure we’re there when others need it most.
So now that it’s really up to you, what will you and your family do? Will you get health insurance if you currently don’t have it? Will you be willing to pay more for improved coverage, because paying more now helps ensure that people who have health conditions won’t lose their coverage, or that you won’t lose yours if you get sick in the future? It’s a lot to think about. It’s a lot of change.
As we all start this journey together, we should remember that our healthcare system was truly broken. More than 50 million people were without coverage. Hospitals and insurance companies were both counting the profits from encouraging repeat visits and dropping insurance the second someone had a real problem and needed it most. Millions of people could not even obtain insurance because of preexisting conditions, and millions more lived in fear of losing their coverage or paying more for it because they or another family member became ill. And the truth is, we who are covered were paying for all that care anyway—through higher insurance, taxes, and higher costs within hospitals and medical systems. There was a lot to fix. There still IS a lot to fix. Maybe the PPACA isn’t perfect. Maybe there is a lot we need to do to improve it. But one thing is for sure: It’s a start.
Now let’s get on with running our democracy properly.