by Sue Saltmarsh

There is nothing more plentiful than confusion when it comes to the Patient Protection & Affordable Care Act (some call it “Obamacare” but because it isn’t what Obama wanted, I call it the ACA).  The Act itself is over 900 pages in length and with all that’s happening with the sequestration, the deficit, and the debt ceiling, much of the language of the bill seems outdated or moot. However, having read several summaries (I found the Community Catalyst ones most helpful), here is an overview (from March 9, 2013) of the provisions of the law listed by the year they went, or were/are supposed to go, into effect.

2010

• No more denying coverage to children with pre-existing conditions. The new rules prevent insurance companies from denying coverage to children under the age of 19 due to a pre-existing condition. In effect, except for insurance companies who decided to discontinue covering ANY children.
• No more rescinding coverage. In the past, insurance companies could search for an error or other technicality on a customer’s application in order to use it as an excuse to deny payment for services when he or she got sick. The healthcare law makes this illegal. In effect.
• Elimination of lifetime caps on benefits. Under the law, insurance companies are now prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays. In effect.
• Regulation of annual limits. Under the law, insurance companies’ use of annual dollar limits on the amount of insurance coverage a patient may receive are restricted for new plans in the individual market and all group plans. In 2014, the use of annual dollar limits on essential benefits like hospital stays will be banned for new plans in the individual market and all group plans. In effect, though the vociferous fight over the medical loss ratio (see 2011) makes me think it’s not set in stone.
• Appealing insurance company decisions. The law provides consumers with a way to appeal coverage determinations or claims to their insurance company, and establishes an external review process. In effect, though no evidence points to it being particularly effective.
• Establishing Consumer Assistance Programs (CAPs) in the states. Under the law, states could apply to receive federal grants to help set up or expand independent offices to help consumers navigate the private health insurance system. These programs would help consumers file complaints and appeals; enroll in health coverage; and get educated about their rights and responsibilities in group health plans or individual health insurance policies. The programs were also supposed to collect data on the types of problems consumers have, and file reports with the Department of Health and Human Services to identify areas that need further oversight. Grants began being awarded in October 2010, but federal funding for CAPs was eliminated in 2012 and has not been reinstated.
• Providing Small Business Health Insurance Tax Credits. Up to 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers. The first phase of this provision provided a credit worth up to 35% of the employer’s contribution to the employees’ health insurance if there were 25 or fewer full-time equivalent employees making an average wage of $50,000 or less per year. Small non-profit organizations can receive up to a 25% credit.  In effect.
• Medicare Prescription Drug “Donut Hole” relief.  Each eligible senior should have received a one-time check for $250. Too bad if you hit that donut starting in 2011. First checks were mailed in June, 2010, and continued monthly throughout 2010 as seniors hit the coverage gap. 
• Free Preventive Care. All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay, or co-insurance. In effect.
• Preventing Disease and Illness. A $15 billion (over 10 years) Prevention and Public Health Fund will invest in proven prevention and public health programs such as smoking cessation and combating obesity. Funding did begin in 2010, but President Obama signed legislation on February 22, 2012 that cuts the fund by $5 billion over 10 years to help pay for a continuation of payroll tax breaks, among other things. Earlier, Congressional Republicans had targeted the fund for cuts or complete elimination. Thanks to the sequester being allowed to go into effect, the Fund will be slashed further by $76 million. So what started at $15 billion has now been reduced to $9 billion, 924 million over 10 years This is just the first of many provisions (most of which are the most popular and help the most people) that Republicans will use as weapons in budget and deficit negotiations, which is why I believe it will never be funded as it was meant to be. In effect, but questionable and endangered.
• Cracking Down on Healthcare Fraud. Efforts to fight fraud returned more than $2.5 billion to the Medicare Trust Fund in fiscal year 2009 alone. The law invests new resources and requires new screening procedures for healthcare providers to boost these efforts and reduce fraud and waste in Medicare, Medicaid, and CHIP. in effect.
• Providing Access to Insurance for Uninsured Americans with Pre-Existing Conditions. The Pre-Existing Condition Insurance Plan provides coverage options to people who have been uninsured for at least six months because of a pre-existing condition. States have the option of running this program in their state (Illinois does). If a state chooses not to do so, a plan will be established by the Department of Health and Human Services in that state. In Illinois, and several other states, premiums for these plans have proven to put them, like COBRA, out of reach for most average Americans, let alone those who fall into the gap between being eligible for Medicare or Medicaid and being wealthy enough to afford the cost of premiums, high deductibles, and co-pays.. Unless you are young, don’t smoke, and can afford hundreds of dollars a month in premiums and thousands in deductibles, this insurance is no more accessible than is the care you need for a chronic condition. National program was in effect, but DHHS announced on February 15, 2013 that new applications for coverage will not be accepted after March 2, 2013.
• Extending Coverage for Young Adults. Under the law, young adults are allowed to stay on their parents’ plan until they turn 26 years old (in the case of existing group health plans, this right does not apply if the young adult is offered insurance at work). In effect.
• Expanding Coverage for Early Retirees. Too often, Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until (if ever) more affordable coverage is available through the new Exchanges, the new law creates a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents. There is an Early Retiree Reinsurance Program website at www.ERRP.gov, though it’s pretty confusing itself. Applications for employers to participate in the program became available June 1, 2010. There were no data I could find on how many have applied.
• Rebuilding the Primary Care Workforce. To strengthen the availability of primary care, there are new incentives in the law to expand the number of primary care doctors, nurses, and physician assistants. These include funding for scholarships and loan repayments for primary care doctors and nurses working in underserved areas. Doctors and nurses receiving payments made under any state loan repayment or loan forgiveness program intended to increase the availability of healthcare services in underserved or health professional shortage areas will not have to pay taxes on those payments. Though this is undeniably a good idea, the funding for it is part of the Prevention and Public Health Fund, which has already been cut and chances are these scholarships and loan programs will not survive for long, if they have thus far. Technically in effect, but endangered.
• Holding Insurance Companies Accountable for Unreasonable Rate Hikes. The law originally allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases to be eligible for $250 million in new grants. That grant money was slashed and starting on September 1, 2011, health insurers “must justify any rate increase of 10% or more before the increase takes effect.” The problem is the widespread conflicts of interest that have been reported in many states, with insurance company executives or elected officials that rely on insurance company money for their campaigns being in positions of influence over review boards. There is no language in the law that creates a consistent standard and many companies are getting away with increases greater than 10% because of “rising costs” in the area, etc. In other words, technically in effect, but not very effective in the real world. “Insurance companies with excessive or unjustified premium increases may not be able to participate in the new health insurance exchanges in 2014,” the operative word being “may.” Of course, if there ARE no exchanges in certain states by 2014, what do they care? Since they’ll still be able to sell policies in states with no exchanges, or even in states that have exchanges if the plan doesn’t meet the “qualified health plan” threshold, they may decide that participation in exchanges is not to their advantage after all.
•  Allowing States to Cover More People on Medicaid. States are supposed be able to receive federal matching funds for covering additional low-income individuals and families under Medicaid for whom federal funds were not previously available. The Supreme Court ruling in June of 2011 made it possible for states (most with Republican governors and/or legislatures) to refuse to expand Medicaid to the “takers” (you know, those poor people who are just waiting for government hand-outs) among their populations. Though to date, six Republican governors have “rethought” their initial decision to reject the expansion and the federal dollars that would come with it, there are still 16 states (as of Feb. 7) that refuse to expand Medicaid. Based on the attacks on Medicare and Medicaid in Congress, I believe this provision will never be funded or implemented fully, perhaps leaving the door open for more medical bankruptcies, hospitalizations, and deaths in those states.
• Increasing Payments for Rural Healthcare Providers. Today, 68% of medically underserved communities across the nation are in rural areas. These communities often have trouble attracting and retaining medical professionals. The law provides increased payment to rural healthcare providers to help them continue to serve their communities. Supposedly in effect, though I could find no evidence and chances are if it does exist, it will be hit by the sequester cuts.
• Strengthening Community Health Centers. The law included new funding to support the construction of and expansion of services at community health centers, allowing these centers to serve some 20 million new patients across the country.  Unfortunately, most of the money intended for this was cut in 2011 and it remains a bargaining chip in debt ceiling negotiations. Not in effect.

2011

• Offering Prescription Drug Discounts. Seniors who reach the coverage gap will receive a 50% discount when buying Medicare Part D covered brand-name prescription drugs. Over the next ten years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020, if it actually is. In effect.
• Providing Free Preventive Care for Seniors. The law provides certain free preventive services, such as annual wellness visits and personalized prevention plans for seniors on Medicare. Not stated is the caveat “if you get them from a doctor or other healthcare provider who accepts assignment.” Finding a provider who takes Medicare might be the biggest challenge and if you’re a woman who gets mammograms at Planned Parenthood, you may be out of luck soon. In effect.
• Improving Healthcare Quality and Efficiency.  The law establishes a new Center for Medicare & Medicaid Innovation that tests, or demonstrates, new ways of delivering care to patients. These methods are expected to improve the quality of care, and reduce the rate of growth in healthcare costs for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Additionally, HHS was supposed to submit a national strategy for quality improvement in healthcare by January 1, 2011 – it actually did so on March 21, 2011. The Center is in effect.
• Improving Care for Seniors after They Leave the Hospital. The Community Care Transitions Program will help high risk Medicare beneficiaries who are hospitalized avoid unnecessary readmissions by coordinating care and connecting patients to services in their communities. Amazingly, no budget cuts have affected this program and there are now 102 organizations participating in these transition programs, resulting in an estimated 700,000 in 40 states having access to these services and preventing 70,000 Medicare readmissions in 2012. In effect until 2016.
• Establishment of the Independent Payment Advisory Board. The Independent Payment Advisory Board was supposed to begin operations in October, 2011 to “develop and submit proposals to Congress and the President aimed at extending the life of the Medicare Trust Fund.” Controversy has surrounded the IPAB*, mostly due to the “doc fix” issue. A 2009 Kaiser Health News article predicted primary care doctors would likely see benefits from an “independent Medicare commission because the panel would be more likely to increase their fees and lower specialists’ rates.” While payment cuts to hospitals and hospices are supposedly off-limits until 2020, and clinical laboratories are off limits until 2016, physician fees may be cut unless a doc fix to Medicare’s sustainable growth rate formula makes those cuts off limits.” It remains to be seen A) whether or not the IPAB will remain as intended, B) be rendered toothless by various lobbying efforts, and C) would even be moderately successful at its original mission.  Not in effect.

*Note: On February 15, 2013, 32 Republican senators introduced S 351, a bill to repeal the provisions of the Patient Protection and Affordable Care Act providing for the Independent Payment Advisory Board. There’s been no movement on the bill and no other co-sponsors so far.

• Increasing Access to Services at Home and in the Community. The Community First Choice Option allows states to offer home- and community-based services to disabled individuals through Medicaid rather than institutional care in nursing homes. Effective beginning October 1, 2011. However, in states that are cutting Medicaid, these services are usually among the first to go. Disabled people, especially children not covered by their parents’ insurance, may be left with reduced services and nowhere to turn.
• Bringing Down Healthcare Premiums. To ensure premium dollars are spent primarily on healthcare, the law generally requires that at least 85% of all premium dollars collected by insurance companies for large employer plans are spent on healthcare services and healthcare quality improvement. For plans sold to individuals and small employers, at least 80% of the premium must be spent on benefits and quality improvement. This is what’s known as the “medical loss ratio.” If insurance companies do not meet these goals, because their administrative costs or profits are too high, they must provide rebates to consumers. Effective January 1, 2011. Before this provision went into effect, insurance companies tried and tried to get agents’ commissions included as “healthcare services.” Though Secretary of Health & Human Services Kathleen Sebelius held strong, something tells me we should be prepared to see this battle take place over and over again. Word has it that rebate checks were actually mailed out – once. However, I have yet to meet anyone who actually got one. Like most provisions in the ACA, the language is vague; there is no oversight of insurance company operations or budgets, and no way to know that they are being compliant with the law. Some advocates argue that the companies may decide that the amount they’d have to pay in “rebates” doesn’t even come close to what their profits would be if they still refused to pay claims for more expensive costs.
• Addressing Overpayments to Big Insurance Companies and Strengthening Medicare Advantage. Today, Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than is spent per person in traditional Medicare. This results in increased premiums for all Medicare beneficiaries, including the 77% of beneficiaries who are not currently enrolled in a Medicare Advantage plan. The law levels the playing field by gradually eliminating this discrepancy. People enrolled in a Medicare Advantage plan will still receive all guaranteed Medicare benefits, and the law provides bonus payments to Medicare Advantage plans that provide high quality care. Effective January 1, 2011. The operative word there is “gradually” – the elimination of the discrepancy may never be complete and I predict the insurance companies will find some other way to keep

2012

• Linking Payment to Quality Outcomes. The law establishes a hospital Value-Based Purchasing program (VBP) in traditional Medicare. This program offers financial incentives to hospitals to improve the quality of care. Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, healthcare- associated infections, and patients’ perception of care. Effective for payments for discharges occurring on or after October 1, 2012. Who knows? If it is indeed in effect as intended, it might make a difference, but once again, who is in charge of oversight?
• Encouraging Integrated Health Systems. The new law provides incentives for physicians to join together to form “Accountable Care Organizations” (ACOs) These groups allow doctors to better coordinate patient care and improve the quality, help prevent disease and illness, and reduce unnecessary hospital admissions. If ACOs provide high quality care and reduce costs to the healthcare system, they can keep some of the money that they have helped save. This is, I believe, window dressing for the old HMO model. I have the HMO plan of my agency’s insurance and the two major priorities, as far as I can tell, are making sure I have referrals from my primary care doctor, and when there are none of the specialists I need in my “network,” that I am assigned to the cheapest alternative outside the network. Most of my doctors are good and I have no complaints about them, but whenever anything is incentivized by money, you’re asking for corruption.  Effective January 1, 2012.
• Reducing Paperwork and Administrative Costs. Healthcare remains one of the few industries that relies on paper records. The new law will institute a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information. Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care. All of my doctors have been forced to make this transition. While it certainly does save paper, there is now a new species of waiting in the doctor’s office – waiting for the computer to boot up, for the nurse or physician’s assistant to determine if he/she has the correct record, for the doctor to enter new information correctly. I suspect most of this is just learning curve stuff and it will get better, but what happens when some 16-year-old hacker decides to wipe out the entire U.S. healthcare system by deleting all those electronic records in one fell swoop? Technology is great, until it isn’t. I just hope major back-up is done constantly! First regulation effective October 1, 2012.
• Understanding and Fighting Health Disparities. To help understand and reduce persistent health disparities, the law requires any ongoing or new federal health program to collect and report racial, ethnic, and language data. The Secretary of Health and Human Services will use this data to help identify and reduce disparities. If the collection of data was the answer to these kinds of conundrums, we would know why HIV affects blacks more than any other race; why abused women stay with their abusers; why poor people who can barely afford food somehow scrape together the money to perpetuate their addiction. The fact is that data collection and analysis is only part of the process. We have to have the courage and tenacity to go beyond the data and ask WHY. And then we have to have legislators who are willing to do something about it instead of dismissing the people involved as “takers,” unable to break their dependence on the government and unwilling to take responsibility for their lives. To understand and fight disparities, you have to care enough to ask those whys. Effective March 2012
• Providing New, Voluntary Options for Long-Term Care Insurance. The law was to create a voluntary long-term care insurance program – called CLASS — to provide cash benefits to adults who become disabled.  On October 14, 2011, Secretary Sebelius transmitted a report and letter to Congress stating that the Department does not see a viable path forward for CLASS implementation at this time. And why not? I admit I haven’t read that report, but I suspect it was because, like COBRA and the Pre-existing Condition insurance, both of which are also “voluntary,” no one could afford it, certainly not a disabled person living on Social Security disability. Not in effect

2013

• Improving Preventive Health Coverage. To expand the number of Americans receiving preventive care, the law provides new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost. Great if your state still has Medicaid, but for those states that have cut their programs to the bare essentials, there may be no funding for this, cost-effective as preventive care is proven to be. Effective January 1, 2013
• Expanding Authority to Bundle Payments. The law establishes a national pilot program to encourage Medicare hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care.  Although the Centers for Medicare & Medicaid Services (CMS) delayed the implementation of this pilot, the Center for Medicare and Medicaid Innovation began a parallel initiative. Under payment “bundling,” hospitals, doctors, and providers are paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundles of items or services are billed separately to Medicare. For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a “bundled” payment that provides incentives to deliver healthcare services more efficiently while maintaining or improving quality of care.  It aligns the incentives of those delivering care, and savings are shared between providers and the Medicare program. Effective no later than January 1, 2013. Though the pilot programs have not operated long enough to garner any significant conclusions, there are now 450 organizations across the country participating in the programs.
• Increasing Medicaid Payments for Primary Care Doctors. As Medicaid programs and providers prepare to cover more patients in 2014, the Act requires states to pay primary care physicians no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services. The increase is supposed to be fully funded by the federal government. This goes back to the states and their stance on Medicaid – will they still get the funds if they don’t expand their Medicaid programs and if so, will the funds really go to primary care docs? Time will tell. Effective January 1, 2013
• Providing Additional Funding for the Children’s Health Insurance Program. Under the law, states will receive two more years of funding to continue coverage for children not eligible for Medicaid. Effective October 1, 2013. CHIP is exempt from sequestration cuts…so far.

2014 and Beyond

It’s rather pointless to even attempt to present a concrete scenario for 2014 and beyond. Too much can happen—the 2014 election could well put current Republican governors out to pasture and give Democrats control of both the House and the Senate. States could have such trouble implementing insurance exchanges, Medicaid expansion, and rural access that they throw their hands up in frustration and give up. So many medical bankruptcies, homelessness, and deaths could happen that there will be a massive uprising to put a stop to it and establish single-payer healthcare. Republicans could be successful in repealing or defunding the law, as Paul Ryan has said he will focus on.

Below you’ll find descriptions and predictions that are a mix of what is supposed to be and my (some might say cynical) view of what is likely to happen. I don’t claim to be clairvoyant or prescient, just not gullible or naïve. I’ve heard so many people insist that “the ACA is the law of the land” and in the face of everything the Wrong Right has done since President Obama was elected and then re-elected, I can’t believe that any reasonably intelligent adult could be so idealistic as to think that means a thing! Roe v Wade is also the law of the land, has been for decades, and yet all you have to do to gauge the level of foaming-at-the-mouth insanity in Congress is count how many superfluous, misogynistic, just plain stupid bills were introduced in the 112^th Congress that had anything to do with abortion, not to mention the number of them that have already started to pile up in the 113^th. The Voting Rights Act has been the law of the land for 50 years and yet the Supreme Court may strike down Section 5, rendering it pointless in the places where it is needed the most. In any case, it seems crystal clear that nothing is guaranteed just by virtue of being “the law of the land. But this is what the law says.

2014

• Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. In 2014, the law will prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Unless insurance company lobbyists prevail in efforts to repeal this provision or Congress renders it toothless by amending it, it will be effective January 1, 2014.
• Eliminating Annual Limits on Insurance Coverage. The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive. Again, insurance companies may lobby successfully or find a way to wriggle out of this, but if not, it will go into effect January 1, 2014.
• Ensuring Coverage for Individuals Participating in Clinical Trials. Insurers will be prohibited from dropping or limiting coverage because an individual chooses to participate in a clinical trial.  This applies to all clinical trials that treat cancer or other life-threatening diseases. I suspect those qualifications will be the basis for insurance companies to circumvent this provision – what about diseases that are chronic, manageable, and may not be immediately life-threatening (HIV, HCV, diabetes, Alzheimer’s, etc.), but which need better, more effective treatments? Effective January 1, 2014, if all goes well.
• Making Care More Affordable. A major provision of the ACA, tax credits to make it easier for the middle class to afford insurance will become available for people with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage. 2013 Federal Poverty Level is $11,490 for an individual and $23,550 for a family of four—400% would be $45, 960 and $94,200 respectively. The tax credit is advanceable, though I suspect that in formulating rules for the provision there may be restrictions imposed, so it can lower your premium payments each month, rather than making you wait for tax time. It’s also refundable, so even moderate-income families can receive the full benefit of the credit. Some people may also qualify for reduced cost-sharing (co-payments, co-insurance, and deductibles). But you still have to come up with the cash to pay your share of the premium and the co-pays, co-insurance, and deductibles, so people who can’t go to the doctor now because they don’t have the $20 co-pay will still not be going to the doctor and the sky-high deductibles that usually go with “affordable” premiums will continue to prevent people from having necessary treatments and procedures until it’s ER time. Plus, there is always the possibility that Congress will somehow gut this provision and there seem to be several opportunities for disaster—at the time of this writing, final rules about the tax credits have not been crafted and there is not as yet any indication of how, or if, the implementation of this part of the law will be affected by sequestration or other cuts. So anyone who seriously believes this whole convoluted, theoretical system will somehow magically fall into place by its effective date of January 1, 2014 is in danger of major disappointment at the very least.
• Establishing Affordable Insurance Exchanges. Starting January 1, 2014 (I’ll believe it when I see it), if your employer doesn’t offer insurance, you are supposed to be able to buy it directly from an “Affordable Insurance Exchange.”  An Exchange is a new “transparent and competitive” insurance marketplace where individuals and small businesses can buy affordable, qualified health benefit plans.  (Notice how many times the word “affordable” is mentioned? My question is who decides what’s “affordable?”) Exchanges will offer you a choice of health plans that meet certain benefits and cost standards.  Starting in 2014, Members of Congress will be getting their health care insurance through Exchanges (the “platinum” plan, undoubtedly), and you will be able buy your (“bronze” plan) insurance through Exchanges too. There is SO much that isn’t said here and so much that’s left up in the air. The question of just what “essential health benefits” will be offered by every plan and the additional ones you get by paying more is not decided. As someone with multiple co-morbidities who would only be able to afford the bronze plan, will I still be able to get the endoscopy I need every six months, the ultra sounds, the blood work? Will all six of my prescription drugs be covered? And as my liver disease progresses and I need more and more specialized care, medications, and tests, will I or my family end up bankrupt because my crappy insurance only covers two primary care visits and one CBC blood test per year, no specialists, and perhaps other procedures that  currently help me manage my condition? What’s to stop all the insurance companies from joining together to set those “competitive” prices so that people essentially have no choice?Also, though subsidies will supposedly be available for those making less than 400% of FPL, even those making up to 133% of FPL will have to pay 2% of their income for just their premium. So if you’re making $14,856, you have to come up with $297.12 per year ($24.76 per month) just to pay your premium. If you’re making 300% of FPL ($33,510, grossing $2,793 per month), you’re expected to pay 9.5% of your income ($265.33 per month), two times what you’d pay under the proposed funding for single-payer. All people who buy coverage through an Exchange would have a cap on their total out-of-pocket spending, including deductibles, co-pays and co-insurance. These limits are based on the out-of-pocket limits that apply to high-deductible plans used with Health Savings Accounts (HSAs). People making under 400% FPL will get subsidies based on their income ($2,975 for those making 300% FPL). Charts for this info are at http://101.communitycatalyst.org/aca_provisions/subsidies. So for someone making 300% FPL the cost for your premiums, co-pays, deductibles, and co-insurance would be $6158.96 per year. Subsidies are supposed to be paid directly to insurance companies, but there is no language about what happens if they aren’t paid on time, if the check gets “lost in the mail” (if the USPS even exists by 2014). We all know what happens if you don’t pay your premium—will bureaucratic screw-ups or malfeasance cause massive cancellations of coverage? Also, like much of the entire Affordable Care Act, this provision relies on we, the consumers, trusting that insurance companies will actually follow the intent, as well as the letter, of the law when we’ve already seen plenty of evidence that their one concern is making money, regardless of whether their customers receive the medical care they need. We do not trust them and I highly doubt that the Exchange experience will inspire us to. It’s way too easy to imagine millions of low and middle income people deciding not to throw away another dollar paying for insurance that provides miniscule or no care, mandate be damned. And then how many uninsured people will there be? How many empty doctors’ offices and standing-room-only ERs will there be?

  Note:  On March 12, 2013, 24 states and D.C. had chosen plans that meet the “essential health benefits” rules released by DHHS in February. The core set of benefits must cover 10 broad categories, such as emergency services, maternity and pediatric care, prescription drugs, and mental health and substance-abuse services. Nineteen states chose existing small-group plans, or the typical employer-based plans for businesses with fewer than 50 employees. The other five states opted for HMO or state employee benefit plans. For states that did not select a benchmark plan, the federal government will designate the largest small-group plan in the state as the benchmark.

  Karen Ignagni, president and CEO of the trade group America’s Health Insurance Plans, has said that the minimum standard “will still require many individuals and small businesses to purchase coverage that is more comprehensive and more expensive than they choose to purchase today.”

• Increasing the Small Business Tax Credit. Starting in 2014, the second phase of the small business tax credit for qualified small businesses and small non-profit organizations kicks in. In this phase, the credit is up to 50% of the employer’s contribution to provide health insurance for employees. There is also up to a 35% credit for small non-profit organizations. Yes, give the non-profits LESS credit because surely they have more money to pay for insurance than for-profit companies do. Seriously? And even though it’s better than nothing and ostensibly business-friendly, because it’s in the law that this president passed, won’t Republicans use this provision as a ransom demand in some future financial finagling? Supposed to be effective January 1, 2014.

• Increasing Access to Medicaid. Americans who earn less than 133% of FPL ($15, 281 for an individual, $31,322 for a family of four) will be eligible to enroll in Medicaid IF the state they live in is participating in the expansion. States will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years. As of February 22, 13 states, all with Republican governors, have refused to participate. In addition, many of the states that do plan to participate have already cut their Medicaid programs so much that the expansion may be more of a resumption for people that got shut out due to cuts rather than opening up the rolls to those who weren’t eligible before, the goal of the provision. Plus, there’s no telling what Congress might do to this provision before next January. Supposedly effective January 1, 2014.
• Promoting “Individual Responsibility.” Don’t you just love the implication that forcing us to buy a potentially useless product is supposed to motivate us to be “personally responsible?” The assumption that anyone who has little or no access to care is irresponsible, lazy, just not willing to pay for what they need with the oodles of cash they have stashed under their mattresses? For once, I agreed with Republicans—the mandates IS unconstitutional, but not just that, it’s immoral and just plain mean and so far from what I believe to be Democratic principles that it was the most blatant, undeniable evidence of lobbying money’s power to control the democratic process that I’ve ever seen (though Citizen’s United comes in a close second). Under the law, most individuals who can afford it will be required to obtain “basic” health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans (in short, no change from now when we pay into Medicare/Medicaid, except we’ll also have to pay insurance companies tons more for crap and still not get the care we need.). If “affordable” coverage is not available to an individual, he or she will be eligible for an exemption, so why bother with the mandate to begin with? Oh, I know all about how it’s supposed to even out risk pools and prevent insurance companies from only covering healthy people, but can anyone seriously believe they won’t find a way to game that system?. Just the condescending language of this provision is bad enough, but the issue of what “basic health insurance coverage” consists of rises again. If people are forced to buy high-deductible, low-benefit insurance, they’re throwing money away and getting nothing in return. If a catastrophic illness strikes or they’re hit by a bus, they would still be essentially uninsured and dependent on ER care, vulnerable to bankruptcy and homelessness. How does that “promote individual responsibility?” Because the insurance companies benefit, this is perhaps the one provision that actually WILL be effective on January 1, 2014.

2015

• Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. Of course, this would rely on the IPAB (or some other regulatory body) to assess the quality of care and the IPAB (or something else like it) is non-existent now and seems likely to remain so. While most physicians support establishing high quality standards of care as opposed to the current fee-for-service model that promotes duplicative testing, unnecessary treatment/procedures, and frequently results in doctors having to spend less time with patients in order to meet quotas, the less-than-objective term “quality” is troublesome to some. I imagine much will depend on what happens with the “doc fix” for Medicare providers and if rules for this provision restrict physicians from refusing to take patients who are insured through Medicare, Medicaid, and low-benefit Exchange plans. I really can’t see this provision being implemented as is – perhaps with some amending. Supposedly effective January 1, 2015.
• The Basic Health Program (BHP) is an optional coverage program under the ACA that allows states to use federal tax subsidy dollars to offer subsidized coverage for individuals with incomes between $15,971 and $22,980 who would otherwise be eligible to purchase coverage through state health insurance Exchanges. This program was supposed to go into effect in 2014, but in February 2013, implementation was postponed for a year. Federal officials have yet to provide details about how the program will be financed, administered, and certified, and states are struggling to evaluate the BHP’s impact on the viability and effectiveness of state Exchanges. Federal regulations may help states decide if they want to participate, but are unlikely to reduce the complexity of implementation or eliminate the financial risk to the states if they establish a BHP and then federal funding is cut or eliminated. It seems quite possible that this program will be left by the wayside, as logistics and funding remain significant hurdles.

Conclusion

As I’ve said, there are several good things that the ACA provides, but there are also even more that lend themselves to various interpretations, non-compliance, and even downright corruption and fraud. The large majority of the American public doesn’t know and doesn’t care about the nitty-gritty details. Their main concerns are:

• How much will I have to pay just to walk into a doctor’s office?
• Will I be able to go to the doctor, dentist, or optometrist (or take my child) whenever there’s a need for medical attention?
• Will I be able to see the doctor(s) I trust who know me and my history?
• How much will my premiums, deductible, and co-insurance be?
• Will I have to fight with the insurance company to get the treatment, tests, or drugs my doctor says I need?
• If all I can afford is the “bronze” plan, what if I need more?

There is only one way to answer all those questions with what your average consumer wants to hear—honestly. If we establish a national, single-payer healthcare system, you will pay 4.75% of your income (more if you’re wealthy) and get the care you need. No co-pays, no deductibles, no co-insurance, no fighting, no debt, no unnecessary hospitalizations because you put off care until it was too late, no doctors in or out of the “network,” no choosing between mortgage/rent, food, electricity, and medical bills. No 900 pages of confusing, vague, inscrutable language that no one can explain. Only time will tell if my cynicism about the ACA is warranted and if, as Republicans and Libertarians fear, the ACA proves to be a doorway to true universal healthcare.

Unlike many of my fellow liberals, I do not blame President Obama for the mess that the ACA is, since I doubt any of us could’ve gone into that “lion’s den” of insurance, pharmaceutical, and other medical industrial complex players, along with their Congressional lackeys, and come out alive, let alone with even as much as he managed to get. In fact, I believe we must shoulder some of the blame, especially those of us who call ourselves single-payer advocates. As Dr. Claudia Fegan often says, if we want single-payer, we need to make our legislators do it. We, as well as many Congressional Democrats, did not have the president’s back in the past, we didn’t make enough noise, we allowed the public option to be killed without a fight, or at least without a fight that anyone knew about, except the single-payer advocates who were in it.

But it was a different time in 2009 when the ACA was debated, disected, and ultimately passed. Occupy was something that you did in airplane bathrooms. Closets with soldiers inside were still locked in the military. The Voting Rights Act really was the law of the land, as was Roe v. Wade. Teachers, nurses, and first responders were respected and admired and we were willing to protect them and their unions. The idea that any one church could break the law by pointing to religious dogma as justification for denying employees of different faiths the right to healthcare was ludicrous. And 84 people, including 20 children, had not been killed in shootings, largely with legally purchased guns, from College Station to Minneapolis; Seattle, to Newtown.

In those days, the majority of us were proud of ourselves for electing the first black president, for taking one big step further into Dr. King’s “promised land,” not yet aware that there were still plenty of people, including those in Congress, who would prove to hate that president so much – not for the content of his character, but for the color of his skin, for his refusal to “know his place,” for the audacity of his thinking he could change anything in Washington – that they would be willing to violate the accepted, and sometimes even codified, rules of governing, making it impossible for any progress to be made on behalf of the American people without a long, wasteful fight.

But now, in 2013, we’ve seen more of how destructive, selfish, mean-spirited, violent, and stupid our fellow citizens can be; we’ve experienced or observed more injustice, hatred, and oppression; we’ve gotten poorer, sicker, and more frustrated. But we’ve also gotten mad. We’ve taken up signs and banners and megaphones; we’ve Occupied, blogged, SignedOn, Facebooked and Twittered. And we’ve shown Mitch McConnell that he had no power to “make this president a one-term president.” Women showed Republicans that they cannot control our bodies or our vote. We defied fundamentalist haters by increasing the number of states with legal same-sex marriage.  We proved that Karl Rove, Grover Norquist, and the Koch brothers could not overcome our focused will, no matter how much money or how many threats they threw around. We stuck our tongues out at Republicans who tried every dirty trick to stop us and then stood incredulous, slack-jawed and staring, as we stayed in line for five, six, eight hours just to vote for that audacious man who refused to know his place and for Democrats who could begin to bring sanity back to Congress. We started to prove the 50-year-old censored words of a civil rights hero to be true—“We all recognize that if any radical social, political, and economic changes are to take place in our society, the people, the masses, must bring them about.”But we haven’t done John Lewis full honor yet. There is still too much change to achieve, too much injustice to remedy, too much wrong to right.

Dr. King said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” I contend that healthcare and economic equality are the civil rights battles of this age and they are, of course, intertwined. So nurses march to tax Wall Street and traders, bank tellers, and secretaries secretly join Occupy Healthcare. Unions add support of single-payer to their charters, Forbes publishes pro-single-payer comments, and business owners talk in low voices about how great it would be if they only had to pay 4.75% for employees’ healthcare. The people, the masses. It is up to us.