By Charlene Bielema
Editor's note: This is the second of a four-part series about the Affordable Care Act and its impact on the health care system. Monday's article focused on the basics of health insurance, the law's timeline, and what will happen when open enrollment goes into effect Oct. 1. Today's article is about a local program that will lead the way in reaching the uninsured to help them sign up and the services that will be provided under the law.
CLINTON — As she works in her office at the Genesis Visiting Nurses Association in Clinton, Michele Cullen's days are aimed at getting medical services to those who need them and help the Gateway area's residents become aware of how to prevent disease and maintain good health.
Her work now is being underscored by a new responsibility she has attained, that of overseeing a new program in which VNA employees will educate the public about the new Affordable Care Act and reaching the uninsured to help get them signed up for coverage.
What she is putting in place are known as Health Insurance Navigators, three of whom will be hired, paid for by grant money and charged with going out into eastern Iowa and western Illinois to sign up people who no longer have insurance, and educate those who do on what their options are under the law.
As community health manager for Genesis VNA, Cullen knows the vast task ahead of her.
She said there are thousands of uninsured individuals in the five county area — Clinton, Scott and Jackson cities in Iowa and Rock Island and Mercer counties in Illinois — who could begin 2014 without health insurance.
"In just the five counties the navigators will focus on, there are nearly 50,000 uninsured," she said. "We know we won't reach every one of them, but we would like to help enroll about 11,000 individuals."
To do that, she must first hire the navigators, whom she said won't necessarily be health care workers but will understand the health care system; for instance, a new hire could be someone with an insurance background.
Those selected will attend federal navigator training, during which they will learn about all facets of the law. From there, they will be sent out into the field to help train others on how to sign people up for coverage.
She pointed out that many of the people who are uninsured today may be that way because they can't afford it; some may have never had coverage.
The goal is to steer them to the online marketplace, create an account and see what options are available to them at what cost.
The navigators also will work with libraries, which is a point of contact for uninsured people who also will have access to a computer to get to the marketplace. The navigators will lead community education forums, such as through churches, work with the local Extension services and with medical service providers. She also hopes she will be able to get the message out to families through fliers sent home from school.
She also wants medical facilities to hire a person who will serve as a point of contact for uninsured patients when they walk into those facilities. She said that would help people on the spot, get them signed up efficiently and is a better process than sending them home with a list of instructions to figure it out themselves.
Cullen is eager to see the program put in place so residents will have the coverage they need to get healthy and stay that way.
"The preventive services will be a great thing since the goal is making the community healthier," she said.
Focusing on preventive care
According to healthcare.gov, high costs have traditionally caused many Americans to skip out on crucial preventive care services, as some experts estimate that people seek out preventive care at half of the recommended rate. The Affordable Care Act aims to substantially increase the utilization of preventive care services by making many of them free. If your plan is eligible for free preventive care, you may not have to pay a copayment, co-insurance or deductible to receive the recommended services.
Chronic diseases, which often are preventable, are responsible for 7 of 10 deaths among Americans each year and account for 75 percent of the nation’s health spending, according to the Centers for Disease Control and Prevention. The Affordable Care Act requires new health plans to cover and eliminate cost sharing for preventive services recommended by the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices and the Bright Futures Guidelines recommended by the Academy of Pediatrics.
What is Covered?
There is a wide range of services that could be covered by the Affordable Care Act. According to heathcare.gov, these services include blood pressure, diabetes and cholesterol tests, as well as routine vaccinations against diseases such as measles, polio or meningitis.
The law also is designed to cover individual counseling on topics like smoking cessation, alcohol use, losing weight and treating depression.
Services for Women
Especially concerning for women are studies showing that even moderate copays for preventive services such as mammograms or pap smears result in fewer women obtaining this care.
Under the Affordable Care Act, women’s preventive health care services — such as mammograms, screenings for cervical cancer, and other services — are already covered with no cost sharing under some health plans. The law also makes recommended preventive services free for people on Medicare.
• Teens and Young Adults Can Stay on Your Plan: If your children are under age 26, you can generally insure them if your policy allows for dependent coverage.
• Coverage for Children's Pre-Existing Conditions: Job-based health plans and new individual plans are no longer allowed to deny or exclude coverage for your children (younger than age 19) based on a pre-existing condition, including a disability.
• No More Lifetime Limits on Your Care: Insurance companies can no longer impose lifetime dollar limits on essential health benefits and annual dollar limits will be phased out in 2014.
• Preventive Care Is Covered: Many insurers are now required to cover preventive services at no cost to you. This includes new preventive benefits for mothers and vaccinations for kids.
• Insurance Companies Are Held Accountable:Your premium dollars must be spent primarily on health care, not advertising or bonuses for executives, and insurance companies must now publicly justify any unreasonable rate hikes.
• Job-based health plans and new individual plans are no longer allowed to deny or exclude coverage to your baby (or any child younger than age 19) based on health conditions, including babies born with health problems.
• New health plans must now cover certain preventive services without cost sharing.
• Starting in 2014, essential health benefits such as pregnancy and newborn care, along with vision and dental care for children, will be covered in all new individual, small business and Exchange plans.
• Starting in 2014, job-based health plans and new individual plans won’t be allowed to deny or exclude anyone or charge more for a pre-existing condition, including pregnancy or a disability.
• In 2014, if your income is less than the equivalent of about $88,000 for a family of four today and your job doesn’t offer affordable coverage, you may get tax credits to help pay for insurance.
People with disabilities
• Under the health care law, job-based and new individual plans are no longer allowed to deny or exclude coverage to any child younger than age 19 based on a pre-existing condition, including a disability.
• Starting in 2014, these same plans won’t be able to exclude anyone from coverage or charge a higher premium for a pre-existing condition including a disability.
• Insurance companies can no longer drop you when you get sick just because you made a mistake on your coverage application.
• Insurance companies can no longer impose lifetime dollar limits on your coverage.
• Medicaid covers many people with disabilities now and in the future will provide insurance to even more Americans.
• Starting in 2014, most adults younger than 65 with incomes up to about $15,000 per year for single individual (higher income for couples/families with children) will qualify for Medicaid in every state. State Medicaid programs also will be able to offer additional services to help those who need long-term care at home and in the community.
• Under the health care law, your existing guaranteed Medicare-covered benefits won’t be reduced or taken away. Neither will your ability to choose your own doctor.
• Millions of people with Medicare received cost relief during the law's first year. If you had Medicare prescription drug coverage and had to pay for your drugs in the coverage gap known as the "donut hole," you received a one-time, tax free $250 rebate from Medicare to help pay for your prescriptions.
• If you have high prescription drug costs that put you in the donut hole, you now get a 50 percent discount on covered brand-name drugs while you’re in the donut hole. Between today and 2020, you’ll get continuous Medicare coverage for your prescription drugs. The donut hole will be closed completely by 2020.
• Medicare covers certain preventive services without charging you the Part B coinsurance or deductible. You will also be offered a free annual wellness exam.
• The life of the Medicare Trust Fund will be extended as a result of reducing waste, fraud and abuse, and slowing cost growth in Medicare, which will provide you with future cost savings on your premiums and coinsurance.
• Insurance Companies Can’t Deny Coverage to Women. Before the Affordable Care Act became law, most insurance companies selling individual policies could deny coverage to women or charge them more due to pre-existing conditions, such as cancer and having been pregnant. Under the law, insurance companies are already banned from denying coverage to children because of a pre-existing condition. In 2014, it will be illegal for insurance companies to discriminate against anyone with a pre-existing condition.
• Women Have a Choice of Doctor. All Americans joining new insurance plans can choose from any primary care provider, OB-GYN, or pediatrician in their health plan’s network, or emergency care outside of the plan’s network, without a referral.
• Women Can Receive Preventive Care Without Copays. Beginning on Aug. 1, 2012, about 1 in 3 women, or 47 million, younger than 65 gained guaranteed access to additional preventive services, like mammograms and birth control, with no out-of-pocket costs.
For example, if the healthcare law were not in place, the average out-of-pocket cost for a mammogram would be $39 and for birth control $78-$185 per year. Under the Affordable Care Act, millions of women can access these services without cost sharing like copayments, co-insurance and deductibles.
• Women Pay Lower Health Care Costs. Before the law, women could be charged more for individual insurance policies simply because of their gender. For example, a 22-year-old woman could be charged 150 percent the premium that a 22-year-old man paid. In 2014, insurers will no longer be able to charge women higher premiums than they charge men. The law takes strong action to control health care costs, including helping states crack down on excessive premium increases and making sure most of your premium dollars go for your health care.
Tomorrow: A look at the program's impact on local facilities and its cost.