The Affordable Care Act: What to cover at the one-year mark
By Joanne Kenen
The Affordable Care Act became law nearly one year ago, on March 23, 2010. The biggest provisions – the state-based exchanges and the subsidies for low and moderate income people to buy insurance – don't go into effect until 2014, but dozens of lesser known programs and provisions are already under way, and most states (including some that are fighting health reform in court) are working on implementation plans.
As the anniversary approaches, here are some topics that reporters may want to look at in their states and communities. You also may want to check in with groups like the American Academy of Family Physicians, major insurers, or your state Medicaid office to find out about what pilots and experiments involving medical homes or other new delivery system models are underway in your state. (Watch for more tip sheets on those topics in the next few months.)
State Health Insurance Exchanges
- States have to make many decisions - where is your state in that process?
- Will they run the exchange or let the federal government do it?
- Who will govern it - an outside body or state government, and if state, what branch?
- Will there be one exchange for small business, and one for individuals, or will they be merged?
- Will a big state have a few exchanges, matching different regions?
- Will small states join forces and have combined exchanges?
- Will the state allow all plans to come in, or what criteria will they set?
- What rules will apply to plans sold outside the exchange?
Health Insurance Exchanges: Key issues for state implementation (RWJF/State Coverage Initiative)
Health Insurance Exchanges: HHS Center for Consumer Information & Insurance Oversight
States and the Affordable Care Act: More Funding, More Flexibility: This is an HHS report on states, related to but not strictly the exchanges. It contains useful information on other aspects of reform's first year.
Health Reform Exchanges: More technical, from Health Reform GPS
Preventive Care for Medicare
In January, Medicare began covering more preventive care services and screenings with no co-pay. Medicare payments for primary care doctors also go up under ACA. Are seniors getting these services? Do they know they are entitled to them? How does this jive with widespread perceptions that Medicare is being cut? Local senior centers and advocacy groups, the state AARP, state medical societies might help. Remember that the ACA will also phase out the "donut hole" coverage gap for Medicare prescription drugs, starting with $250 rebate checks.
How Health Reform Legislation Will Affect Medicare Beneficiaries, from The Commonwealth Fund
Preventive Services Under Medicare, from HealthCare.gov
High Risk Pools
Before ACA, about 35 states had high risk pools to help people who could not get insurance because of pre-existing conditions. But they were very expensive, and all together covered only about 200,000 people nationwide. ACA created a new set of pools - states could either run them on their own, or have the federal government do it for them. They are not as expensive as the old state pools, but still quite expensive. People have to have been uninsured because of a pre-existing condition for at least six months. The initial expectation was that enrollment would be high - and that the $5 billion designated wouldn't be enough. Instead, only 12,000 people had signed up as of early February. The federal government, and some states, are doing more outreach, and making some tweaks in what kind of policies they offer. Is enrollment picking up in your state? Why or why not? Who is eligible but not signing up, and why?
A subtheme - Rather than meet the new requirement that they cover children with pre-existing conditions, some insurers are pulling out of some state markets or threatening to do so. The federally-administered pre-existing condition pools now offer a "child only" option. Is this becoming a fall-back in your state? Do people know about it? How?
State-by-state breakdown of Pre-Existing Condition Insurance Plans, from HealthCare.gov
Insurance Protections for Children in the Affordable Care Act, from HealthCare.gov
Covering high-risk insurance pools: Four reporters who have covered the topic offer story tips, suggestions and resources.
Funding for Community Health Clinics
The 2009 stimulus law and ACA put a lot of new money into federally qualified community health centers. Check out the growth and potential expansion plans in your community. How are they preparing for the Medicaid expansion of 2014? (Medicaid also will pay more for primary care for at least two years.)
The Unresolved Question of Medicaid Reimbursement, by Jonathan Cohn
Community Health Centers: Opportunities and Challenges of Health Reform, Kaiser Family Foundation
Health Reform and Primary Care: The Growing Importance of the Community Health Center, New England Journal of Medicine
ACA sets new rules for nonprofit hospitals. They are the "safety-net" in the health care system, but now the law will make sure that they are really serving the community to get their tax break. This is a topic that has received very little attention in the media. As a report from the Hastings Center said, "A 2007 Internal Revenue Service report stated that about half of nonprofit hospitals spent 3 percent or less of revenues on charity care. Nowadays, hospitals are bringing in large amounts of money, paying their CEOs record amounts of compensation, and engaging in aggressive debt recovery actions."
There are questions about how they define "charity care" too – if they are using high "sticker" prices that few patients pay (insurers and government programs generally negotiate discounts.) There has been talk of more federal legislation to define accounting practices, a class action suit has been filed, and one Illinois court upheld the revocation of a hospital system's state tax exempt provisions.
New Requirements for Tax Exempt Charitable Hospitals, HealthReformGPS
Illinois Supreme Court Rules Provena Must Pay Tax, by Bruce Japsen, Chicago Tribune
What's Left of Charity Care After Health Reform, Hastings Center
Charity Care: How Much is Enough?, by David Wahlberg, Wisconsin State Journal
Changes to 990 forms make hospital finance investigations necessary, from a presentation by The Philadelphia Inquirer's Karl Stark
Investigation finds policies for offering charity care to low-income patients vary widely, by Fred Schulte, The (Baltimore) Sun
Wash. hospital executive salaries may threaten nonprofit status, by John Ryan, KUOW- Seattle public radio
These things, which have gotten a fair amount of national attention, may still be worth looking at one year out in your own state or community:
- Allowing young adults to stay on parents' health plans up to age 26. Plans can't charge them more or offer fewer benefits than for younger children. See "Realizing Health Reform's Potential: Young Adults and the Affordable Care Act of 2010" from The Commonwealth Fund
- Ban on discriminating against children with pre-existing conditions. After 2014, no one can be denied insurance based on pre-existing conditions, but the provision for children went into effect Sept 23, 2010. The federal government estimated up to 72,000 uninsured children would gain coverage.
- Ban on insurance companies dropping coverage (recissions). The government estimated coverage of about 10,700 people would be protected from having their coverage cancelled because they get sick or make a technical mistake on their application. (People who commit fraud on their applications will, of course, not be protected.)
- End on lifetime limit on coverage (annual limits won't be affected until 2014). This will affect about 20,400 people.
- Started covering individuals with pre-existing conditions: On July 1, the administration announced the establishment of the Pre-Existing Condition Insurance Program to provide coverage for eligible
- Subsidies for early retiree insurance
- Tax credits for small business
Health Affairs and the Robert Wood Johnson Foundation have produced a series of short issue briefs on many of these topics. The Alliance for Health Reform, the Kaiser Family Foundation and the Commonwealth Fund also have abundant resources
For conservative critiques of health reform, see the U.S. Chamber of Commerce and National Federation of Independent Business websites, as well as groups like the Heritage Foundation and the American Enterprise Institute.
Physicians for a National Health Program provides a single-payer perspective.