Food Storage & Other Adventures in Motherhood

So what is in the Healthcare Reform Act anyway?

by heather

Last week I attended a nursing education conference. One of the speakers talked about the Patient Protection and Affordable Care Act gave a descent summary of the changes that it will make on health care in the United States. I’ve heard a lot about what is and isn’t in the PPACA, but I’ve heard conflicting things. There’s a reason for the that. The PPACA is almost 2,400 pages long and it is very complex. 2,400 pages, that’s massive. I like to read, but I don’t think I have ever sat down and read anything that long. (The KJV of the Bible is only 1590 pages and I think that’s the longest book I have ever read in its entirety.) I think that I can safely assume that most people aren’t reading that document in its entirety, making it difficult to know what it actually says. So I thought I would sum up what I have learned and share it with all of those moms out there who are wondering how this is going to effect them and their families.
Here are some of the big changes that it includes:

  • Individual Mandate
  • Premium and Cost-sharing Subsidies
  • Employer Responsibility
  • Guaranteed Issue
  • Insurance Exchange
  • Medicaid/CHIP Expansion
  • Wellness Programs
  • Payment Reform

 Ok, I work in health care and I still didn’t know what half of those things meant until someone explained it to me, so I’m going to try to explain them so my readers can also know what’s going on with their health care.
Individual Mandate– This means that the government requires that every individual has some kind of health insurance coverage. If they don’t have coverage they have to pay fines. (This doesn’t begin until 2014.) Right now there are a lot of young healthy people who don’t have insurance because they don’t utilize health care often enough to make health insurance coverage cost effective for them. One of the principles of individual mandate is to spread the risk (cost) of insuring older sick people over a larger group of people.
Premium and Cost-sharing Subsidies- This means that there are limits on how much a person should be expected to pay for health insurance. And there are subsidies to assist people with their health insurance premiums up to 400% of the national poverty level. For example let’s say you have a family of 4 and you make $42K annually. That puts you in the 150-200% of the national poverty level range. The most that you are allowed to pay for your health insurance is 6.5% of your income. This is good news for a lot of people. There are so many people that I know who make too much money to qualify for Medicare, but are fairly crippled by their health insurance premiums, especially if they are not able to get them through an employer. To see where you would fall on the  subsidy chart go here. This one also starts in January, 2014.
Employer Responsibility- This means that all companies that have at least 50 employees are required to offer some kind of health insurance to them, or pay fines. Companies with at least 200 employees must automatically enroll all of their  full-time employees in health insurance, although employees can opt out and receive vouchers that they can use for a health insurance plan of their choosing. Coming January, 2014.
Guaranteed Issue- This is a big one. This means that insurance companies can not deny you coverage for a preexisting condition, and they have to renew your policy also. I can think of dozen people that I personally know who this will help. My best friend’s mom with cancer, my neighbor with diabetes, my father-in-law with a rare genetic disorder, a former co-worker whose husband has sleep apnea, a friend’s son with cerebral palsy are just a few. Everyone of these people are hard-working, tax-paying Americans who because of they have “preexisting conditions” and are unable to get insurance through their employers, do not have health insurance. Some have been lucky so far, others have been almost crippled by medical bills. For children, guaranteed issue started September 23, 2010 (Hooray!) and will start January 1, 2014 for adults.
Insurance Exchange- By January, 2014 states will be required to set up health insurance exchanges, which are like marketplaces. It’s a place where people can compare rates and programs, and hopefully factoring in some competition will improve the available product. But they won’t be available for everyone.
Medicaid/CHIP Expansion- This means that more of those people who right now make “too much” money to qualify for Medicaid/CHIP will be eligible. And even if states have budget short-falls they will not be able to cut funding here until 2019.
Wellness Programs- All qualifying insurance companies will have to provide preventative wellness programs to infants, children and adolescents, such as well-child checks and immunizations. This is effective September 23, 2010. (I love this, because I believe that preventative medicine is more cost-effective. And I think that it is sad that some people who do have insurance still don’t get these things done because it costs them too much money.)
Payment Reform- Medical billing, murg. I know that for me at my job I now have more paper work. (Although compared to some I have nothing to complain about.) I know that Medicare payments are being modified drastically. And Medicare will increase their payments to primary care providers by 10%, because they want to encourage more good doctors to be primary care providers. Having quality primary care will save everyone money. But the bottom line for most Americans is that will taxes will go up to fund these changes.
A few other interesting points- There are now no lifetime limits. So my chronic pediatric patient who burned through more than one million in health care dollars in his first year of life can actually have health insurance as an adult. There are no annual limits. So if you have something catastrophic like a mangling car accident your insurance company can’t say “Sorry we won’t pay for your prosthetic leg because you’ve already cost us too much money this year.” Dependents must be eligible for coverage until the age of 26. (And if you’re married and under 26 you still qualify to be on your parents insurance.) This will make getting through college and graduate school so much easier for a lot of people. When I was in college I knew a guy who only went to school one semester a year because he had to spend the rest of the year working full-time to afford the insurance that was available (and required) from the university. This would be huge for people like him. Goodness it would have made my life a lot easier going through college too. And there will also be limits on how much profit insurance company administrators can make. It’s about time.


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