Trying to understand health care reform — with all the political arguments and lawsuits swirling around it — is like walking into a hurricane.
With 100 mph winds and pounding rain, it’s impossible to nail anything down.
Throughout the coming year, this column hopes to be the Red Cross in this mess. My goal is to show up after the political-legal-bureaucratic storm to help you figure out what just happened.
And the only way to understand upcoming changes to the existing law is to have a clear picture of what’s happened so far.
I’ll try to paint that picture. My goal is to make health care reform — and its effects on consumers — so clear you’ll be able to explain it to your grandmother.
To do that, I’ve talked to folks at the nonprofit Kaiser Family Foundation and J.B. Silvers, a Case Western Reserve University professor of health care finance.
Here are the basics. The health care law had three major goals: to provide insurance to about 30 million more Americans; to stop insurers from doing bad things — canceling coverage when someone gets sick, for example; and to keep health care costs under control.
In the law’s first year, 2010, it made progress toward all three.
More people did obtain coverage — in several ways.
First, the Patient Protection and Affordable Care Act, as it’s called, required insurers to include young adults — up to the age of 26, married or not — on their parents’ plans. (Ohio law, by the way, extends coverage to single children up to 28, in some individual and employer plans.) In the past, many young adults had gone without insurance, especially when full-time jobs with benefits were hard to come by.
Another way health care reform expanded coverage was with the creation of pre-existing condition insurance plans, or PCIPs. They provide coverage for those considered high risk, such as people with cancer, heart failure or depression who have been uninsured for six months or more. Before reform, many of those people were denied coverage, or premiums were so high, they couldn’t afford insurance.
The PCIPS aren’t cheap, and they have their problems. But so far, Ohio’s is now covering about 1,000 people.
More people now are insured because of a third provision, too, one that says new policies can’t deny or limit coverage to children with pre-existing conditions.
Among the 20 or so other changes implemented in 2010 are several that prevent insurance companies from mistreating consumers.
Insurers can no longer limit the total amount they’ll spend on an individual’s care, referred to as a lifetime limit.
New plans also must cover basic preventive tests such as mammograms, immunizations and colonoscopies, with no co-pay.
And insurers can no longer cancel coverage when someone gets sick.
The law is working at reining in costs, too.
Last year it began providing grants to states to look at how much insurance companies raise their premiums annually. Some states have taken that a step further, says Jennifer Tolbert, a health policy expert for Kaiser, and have forced insurers to lower those price increases.
And it’s funding health insurance exchanges. Those exchanges are like markets where individuals and businesses can go to shop for plans and compare them in an apples-to-apples way so they can determine which one works best for them and costs the least.
“It’s to provide consumers with better information that allows them to make informed decisions regarding the purchase of health insurance,” Tolbert says.
Other changes that took effect in 2010 include a 10 percent tax on tanning, the creation of a website that explains what insurance options are available, and a $250 rebate to those who’ve reached the Medicare doughnut hole. The doughnut hole is the point at which Medicare recipients must pay 100 percent of their prescription drug costs. In 2011, Medicare recipients hit that hole after spending $2,840 — including co-pays — on prescription drugs.
More changes affecting consumers take effect this year.
Beginning in 2011, insurers must spend 80 percent to 85 percent of premiums on patient care and quality improvement. If they don’t, they have to refund the difference to their customers.
Drug manufacturers must also cut prices on name-brand drugs by 50 percent for Medicare patients in the doughnut hole.
And Medicare must cover preventive tests such as mammograms, immunizations and colonoscopies, with no co-pay.
Later this year, chain restaurants will have to list the nutrition content of the food on their menus. Vending machine food must, too. The goal here is to get restaurants to offer healthier food and consumers to eat better in the hopes of improving health and reducing costs.
Beginning July 1, the law also puts an end to federal payment to states for the treatment of hospital-acquired infections in Medicaid patients. It’s a stick, to encourage hospitals to stop the infections and, ultimately, reduce costs.
Health care reform changes aren’t all to the consumers’ advantage.
Tax-free health savings accounts can no longer be used to pay for over-the-counter medications not prescribed by a doctor and any portion of them not used for health care will be taxed at 20 percent, up from 10 percent or 15 percent.
If you’re covered by a Medicare Advantage plan, you might notice another change in 2011. Federal payments to those plans will be frozen at 2010 levels. To make up for that loss, some plans may cut extra benefits such as free health club memberships. And some insurers may decide to stop offering Medicare Advantage plans altogether.
Yes, there are other provisions — they affect the training of doctors, for example, or create a Medicare payment advisory board. But the changes noted above are the major ones that change the way health care covers consumers.
It’s a lot to digest.
So I’ll use a future column to talk about changes expected in 2012 and beyond.
Of course, you should know that the law is most likely headed to the Supreme Court because lower courts disagree over whether it’s constitutional.
Congress is fighting over it, too, with Republicans trying to overturn the law and Democrats arguing that is should stay.
What happens next?
The answer is simple: We don’t know — not yet.
But for now, this is the law that’s in place and the one we’ll be living with.
Source: Cleveland