Nearly 1 million Washingtonians are uninsured. By 2014, roughly 800,000 of those residents will be insured via the Affordable Care Act (ACA), according to the Washington State Office of the Insurance Commissioner (WSOIC).
In June, the U.S. Supreme Court deemed the ACA (nicknamed “Obamacare” for President Barack Obama’s sponsorship) constitutional. The nation will continue to phase in the ACA, historically the most sweeping piece of legislation since the Civil Rights Acts of the 1960s.
Washington’s gubernatorial candidate Rob McKenna was one of the 26 attorney generals to join a lawsuit challenging the ACA when passed in March 2010. Since the Supreme Court deemed the law constitutional, McKenna — while accepting the decision in a press release — has yet to clarify his stance on the ACA, according to various news sources.
Politics aside, how will the reforms affect you?
What it includes
Starting in 2010, health-insurance plans must provide preventive-care services for free, without co-pays or deductibles. Preventive services for adults include testing and counseling for blood pressure, cholesterol, depression, Type 2 diabetes, diet, HIV, immunizations, obesity, tobacco use and syphilis. For children, preventative services include testing and counseling for autism, alcohol and drug abuse, immunizations and depression. (For the full list of health conditions covered in preventative-care services, see healthcare.gov.)
The WSOIC expanded preventative services for women in Washington state on Aug. 1. Women now have access to additional services, including HPV testing, counseling for sexually transmitted infections, domestic-violence screening, breastfeeding supplies and contraceptives.
The ACA provides for a Patient’s Bill of Rights, which has garnered praise from people across the political spectrum. This Patient’s Bill of Rights ensures:
•Consumers are not denied coverage because of a preexisting condition (including pregnancy, asthma, acne, depression and cancer).
•Children under age 26 are allowed to stay on a parent’s health plan. Young adults are eligible even if they are married, not living with the parent, attending school or not financially dependent on the parent.
•Insurance companies cannot increase rates without justification. They must spend 80 to 85 percent of consumers’ dollars on primary health care, not on administrative costs.
Insurers also must end lifetime limits on coverage.
•Insurance companies cannot rescind a person’s benefits if the company finds a mistake in the application. If an insurer decides to cancel someone’s coverage, it must give the individual 30 days’ notice, allowing time to appeal the decision or find new coverage.
The ACA also includes provisions to make Medicare prescription-drug coverage (Part D) more affordable. It does this by gradually closing the gap in drug coverage, known as the “donut hole.” (Currently, while Medicare consumers have much of their health-care costs paid for, those who fall into Part D need to pay largely for their own medications.)
In 2012, consumers who reach the “donut hole” automatically get a 50-percent discount for name-brand drugs and an 86-percent discount for generic drugs. The discounts will progressively increase over the following eight years. By 2020, the donut hole will be closed.
Consumers already enrolled in Medicare Advantage Plans (private insurance plans to defray the medication costs of Part D) will get new savings, as well.
The ACA also expands Medicaid for those who do not earn enough money to purchase insurance through the exchange, even with subsidies.
The Supreme Court struck down a provision requiring all states to expand Medicaid, which elicited praise among several Republican lawmakers. However, federal dollars will still be available for all states to expand Medicaid if they choose. Washington state will expand Medicaid.
Easy insurance shopping
The ACA has each state set up an “exchange,” or marketplace, where people who are not insured through their employers could shop for health insurance at competitive rates. Those who cannot afford the exchange will be given federal subsidies.
Health insurers will be required to provide an easy-to-understand summary about a health plan’s benefits and coverage, according to Healthcare.gov. The new regulation is designed to help consumers better understand and evaluate their health-insurance choices.
All insurance companies must use a plain-language Summary of Benefits and Coverage (SBC), with a uniform glossary of terms commonly used in health insurance coverage, such as “deductible” and “copayment.”
The SBC was designed after the Nutrition Facts label, a federal service required of food manufacturers to help consumers make informed decisions about their diet. The SBC’s standardized information allows consumers to make “apples-to-apples” comparisons among insurance options, according to Healthcare.gov.
This regulation will apply whether consumers receive coverage through employers or purchase it independently. Consumers who do not speak English will receive the SBC and uniform glossary in their native language upon request.
There is a tax, or penalty, for people who do not purchase health insurance in 2014. The tax ensures that both sick and healthy individuals sign up for coverage, keeping insurance premiums affordable, according to The New York Times. The White House also argues the tax enables people to take personal responsibility for the cost of their own health care.
The tax will be phased in from 2014 to 2016. According to Factcheck.org, the minimum tax per person will start at $95 in 2014 and increase through 2016. No family will pay more than three times the per-person penalty, regardless of how many people are in the family.
Reaping benefits already
According to the WSOIC, millions of Washington state residents already benefit from the ACA’s early reforms that started in 2010.
More than 2.4 million people no longer face lifetime caps on their health benefits.
More than 52,000 young adults under age 26 have stayed on their parents’ health plans.
More than 1.2 million people now have coverage for preventive care, with no co-pays or deductibles.
More than 60,000 people on Medicare have saved hundreds on their prescription drugs.
WSOIC spokesperson Rich Roesler said the ability to purchase insurance will be doable once the exchange is in place.
“This is a big deal,” he said. “The odds of uninsured folks buying comprehensive insurance in a competitive marketplace now are very slim. We are confident that 80 percent of those with no insurance in Washington state will be covered. The vast majority will qualify for the subsidies or Medicaid expansion.”
“The ACA allows us to sell a richer set of benefits to individual consumers — not the cheaper plans they get today,” said Eric Earling, spokesperson for Premera Blue Cross and LifeWise Health Plan of Washington. “An individual with a subsidy will be able to access a policy without many out-of-the-pocket costs.”
Moreover, Earling explained the company won’t need to undergo major reforms. It already spends 86 cents of every dollar on medical care — beyond the 80 to 85 cents required by the ACA, he said.
“There’s a stereotype that insurers have a lot of profit, but as a not-for-profit company, that’s not the case,” he said. “Whenever you’re talking about us or Regence BlueShield or Group Health, these are all not-for-profit.”
The exact changes the company will need to make by 2014 are not yet clear. But Earling said the changes would mostly center on insurance purchases made by individuals rather than by employers.
“Once the ACA goes into effect, we anticipate additional newly covered patients to seek care, especially at the primary-care level,” said Dr. Rayburn S. Lewis, senior vice president and COO of Swedish/Cherry Hill medical centers. “[This] should reduce the need for access to the emergency room.”
Lewis predicted that Swedish’s administrative and patient-care costs would not rise.
“Our infrastructure already exists to manage insured patients, so it’s unlikely the new influx will have a major impact there,” he said.
However, Medicaid currently covers only a portion of Swedish’s expenses, and the Medicaid expansion will require improved treatment costs for Medicaid enrollees.
“In that sense, we have to improve our costs of care for an entire population, with emphasis on the right treatment at the right time, preventative care and early treatment of diseases before they become advanced, chronic and more expensive,” he said.
Controversy continues
Not everyone is pleased with the highly partisan ACA or with the Supreme Court decision to uphold the law.
“It’s a bad bill — horrible, awful, atrocious bill written by the insurance companies,” said Fremont resident Scott Sinclair, who is active with King County Young Republicans. “The insurance companies’ stocks went up after the Supreme Court ruling.”
Sinclair said health reform should have included provisions where people could shop for insurance across state lines.
He is concerned that his premiums have gone up 43 percent in two years, despite the fact he is only 43 years old, does not smoke, does not have a preexisting condition and is a 10K runner.
Sinclair values some aspects of the ACA.
“I think you’ll find the majority of Republicans — the majority of the country — want to take care of people with preexisting conditions. Just put people on Medicaid and expand it. That’s one part that went through [that I like] — we’re going to take care of these people.”