I've been following the debate about the health care law and it seems like most commenters are totally for it or adamantly against it. I've been watching my family, friends, and patients face bad choices and rationed health care because of our current health insurance system. What I really want to know is if this law will fix it.
First, let's look at some of the key parts of the Affordable Care Act (ACA), most of which are phased in by 2014:
- The best parts of the law are the provisions that people cannot be denied health coverage because of pre-existing conditions, that insurers can not drop you when you get sick, and that eliminate annual and lifetime caps on coverage. What worries me are the loopholes that insurance company lawyers will use to continue to cherry-pick who they cover. For example, the law doesn't say how much they can charge to cover people with pre-existing conditions.
- Almost everyone (even the insurance companies) agrees that it's good to let parents keep their children, up to the age of 26, on their health insurance (if they have it).
- Large companies that don't give their workers health insurance will have to pay $2,000.
- People who do not have health insurance where they work and choose not to buy it will have to pay a penalty. Is the individual mandate a fee, a tax, or a penalty? I don't really care what we call it. I understand why everyone should be part of the healthcare system. Medicare does this, covering everyone 65 and over. The individual mandate is a clumsier way of creating one risk pool, through private insurance companies. I've don't like it because it requires people to give money to profit-making insurance companies.
- If you are very low income, you may qualify for a government-funded subsidy to buy insurance through a health exchange, or, for the most low income, become eligible for Medicaid which is set to expand.
- It shrinks the Medicare donut hole in prescription drug coverage, where there's coverage to a certain point and then nothing until a higher spending cap is reached. Since 2010, 5.2 million seniors and people with disabilities have saved $3.7 billion on prescription drugs. I believe the donut hole should be entirely eliminated.
- All insurance plans will be required to include preventative care (i.e. mammograms, vaccinations, colonoscopies, physicals) with no co-pay, by 2018.
- Medicare coverage will now include an annual physical and no co-pays for preventative services.
- Before, small businesses paid as much as 18% more than larger businesses for premiums. Now, they will get tax credits (up to 50% of the cost of premiums) for offering health insurance to their workers. In 2011, this affected 2 million employees.
- Pharmaceutical, medical device manufacturers and health insurance companies will have their taxes increased. I agree with this. This law gives them millions of new customers. They can help pay.
- The law increases funding for community health centers, one of the best provisions of all.
- For the first time, the law taxes health benefits, and the main target is the comprehensive, best plans. In 2018, those plans (more than $10,200/single; $27,500/family) will be taxed. The insurance company has to pay, but they're going to pass the cost along to anyone lucky enough to have a good plan. I think this will push more people into plans that cover fewer health needs and have large out-of-pocket costs.
- In 2013, if you make more than $200,00 (individual) or $250,000 (family), you will pay a Medicare tax on investment income (before Medicare tax was only on wages).
- The Medicare tax rate goes up to 3.8%, from 2.9%.
Although the advocates for the law say that it will bring down health care costs. I believe that some of these benefits are over-stated and ignore some remaining very large problems.
What the law doesn't or maybe won't do:
- Despite the all the claims about cost controls for individuals and families, most of them are weak. Insurance companies, drug companies, and hospitals will still largely be able to charge what they want. Although there are limitations on rate increases, this is not enough protection, 9% increases for several years is just as untenable (although it is better than the current, unfettered, increases).
- I expect that people will continue going bankrupt because of high medical bills or choosing to skip or delay doctor visits or needed treatment.
- Insurance companies will still be able to deny care recommended by a doctor using the same excuses ("experimental," "not medically justified," etc) as now.
- I read that the non-partisan Congressional Budget Office said that up to 27 million people will still have no health coverage. Since the Supreme Court decision allows individual states to opt out of the Medicaid expansion for low income people without a federal penalty, that number will probably grow.
- Some people are worried that employers will drop existing coverage because the exchanges will now be a more affordable option. I'm not too worried since before this law, employers could drop or reduce coverage any day they wanted (and many did). There's nothing in ACA which makes it more attractive to drop coverage, in fact they might have to pay a penalty for dropping coverage.
- The law promotes IT systems in healthcare, many of which are wasteful and have been used by some employers to erode RN clinical judgment.
- There are similar misguided incentives for "wellness" programs that penalize people who have diabetes, high blood pressure, or other medical conditions often beyond their control.
- The windfall for insurance companies, big pharmaceutical firms (who were exempted from strong cost controls to win their support for the law), further strengthen a healthcare system already too focused on profits rather than patient need.
For me, the bottom line is the ACA law didn't go far enough. Insurance companies are going to be a little more restricted more than they were in the past. It will help some people but doesn't cover all Americans.
Polls show that a majority of Americans would rather that Medicare cover everyone. We would still have to work to improve it, but it would be easier and more cost-effective. It would eliminate the higher administrative costs (ACA limits insurance companies to 15%, even assuming they don't find ways around that, Medicare's is 3%) and the corporate profits - billions of dollars removed from the health care system and not spent on health care.
