By Charlene Bielema
The Affordable Care Act.
Federal health care.
Whatever it is called, the new healthcare system that will roll out into its final phase over the coming months will have a huge impact on the way American consumers receive health care and how it is delivered by health care facilities.
Today and over the next three days, the Clinton Herald will publish stories about the law — and how it will affect consumers and facilities alike — to give readers a glimpse of what is in store for them.
But first, here are some of the basics about how health care coverage works.
At its core, health insurance is a contract between you and your insurance company. You buy a plan or policy, and the company agrees to pay part of your medical expenses when you get sick or if you are injured. Insurance will cover the care you need even when you need care that costs more than what you pay in premiums and deductibles.
While insurance can be purchased independently or be provided through an employer, 2012 US Census Bureau statistics indicate about 16.3 percent of Americans go without insurance. That could be because a person cannot afford to pay health insurance costs, chooses to go without it or has a pre-existing condition, leaving him or her to either pay higher medical bills or be refused service.
Those issues led to the creation of the Affordable Care Act, which actually refers to two separate pieces of legislation: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. Together they are expected to expand Medicaid coverage to millions of low-income Americans and are intended to expand coverage for all Americans.
The legislation was passed by Congress and signed into law March 23, 2010, with the ultimate goal of ensuring that all Americans — regardless of health status or pre-existing conditions — will have access to affordable health care coverage.
To get there, the law’s goals, according to Healthcare.gov, are to expand coverage, hold insurance companies accountable, lower costs and guarantee more choices for health treatment. It also is meant to fill in current gaps and make overall improvements of the quality of care. It is comprised of various program and funding requirements based on age and medical history.
While some segments of the law already are in place, most will become effective Jan. 1, 2014. Open enrollment into the program will begin Oct. 1, when people will be able to select and apply for health insurance coverage choices in what is known as the Health Insurance Marketplace.
The marketplace, accessed through a federal website — www.healthcare.gov — is up and running but plan and cost information will not be posted until Oct. 1. Insurance coverage will go into effect Jan. 1 and the open enrollment period will end March 31. The last items on the timeline are the tax credits available to middle-class families in 2014.
Each state will have its own way of running the program, said Michele Cullen, community health manager for Genesis VNA. She said once the website is fully in effect, those looking to shop for health care will punch in the zip code in which they live to get to the options available to them. Accounts can be created on the site now to start inputting information.
There will be many components to the new law, according to healthcare.gov. One part of it went into effect in September 2010, when it required most health plans that cover children to expand their coverage for children up to age 26. Estimates from the National Center for Health Statistics showed an immediate impact on the most underinsured segment of the American population, with the addition of 2.5 million young adults who gained coverage, healthcare.gov states.
Also, under the law, 10 health care benefits that will be covered include:
• Outpatient care, which is the kind you get without being admitted to a hospital;
• Trips to the emergency room;
• Treatment in the hospital for inpatient care;
• Care before and after a baby is born;
• Mental health and substance use disorder services. This includes behavioral health treatment, counseling and psychotherapy;
• Prescription drugs;
• Services and devices to help patients recover if they are injured or have a disability or chronic condition. This includes physical and occupation therapy, speech-language pathology, psychiatric rehabilitation and more;
• Lab tests;
• Preventative services, including counseling, screenings and vaccines to keep people healthy and care for managing a chronic disease; and
• Pediatric services.
Specific health care benefits may vary by state. Even within the same state, there could be small differences between health insurance plans.
Backers of the law say it strengthens Medicare, cracking down on waste, fraud and abuse, while also providing new protection offering seniors a range of preventative services with no cost-sharing. It closes the coverage gap – known as the “donut hole” – to provide discounts on drugs when within that time frame. Medicare-covered benefits will not be reduced or taken away. The government will not require a change in that regard, nor in a consumer’s ability to choose a doctor.
Under the new law, as of 2015, virtually everyone in the U.S. will have access to a health insurance plan. Those who are eligible and decline any plan will be taxed each year at tax time at a cost scheduled to increase from $95 (or one percent of family income, whichever is greater) for tax year 2014, to $695, or (2.5 percent of family income,) whichever is greater, by 2016 and beyond.
Tomorrow: A look at the local Navigators program, educating the public about the law’s facets, and more about what it offers.