Clearing Up Confusion About Health Care
How can you keep your family healthy—and what’s it going to cost? In September, Kathleen Sebelius, Secretary of the U.S. Department of Health & Human Services, visited Parents to talk about the Affordable Care Act, or ACA, which went into effect in March 2010. As more features and benefits of the law roll out—including eight new preventive services for women that will be covered in plans that renew on or after August 1, 2012—it’s more crucial than ever that families understand what they’re entitled to. We put out a call on Facebook asking exactly what you wanted to know, and your questions helped shape our conversation with Secretary Sebelius.
Parents: Which parts of the Affordable Care Act most directly affect women and families?
Kathleen Sebelius: In September 2010, preventive services started to be offered without co-pays. This was a way to encourage things like immunizations, folic acid supplements, and mammograms, because we know that preventing a problem [or detecting one early] is cheaper and healthier than treating a problem.
Then, in August 2012, we rolled out a series of benefits aimed specifically at women. They affect your health at every stage of your life, with HIV screening, contraception, and the assurance that your plan will include maternity benefits such as pre- and post-natal care. This includes free gestational diabetes screenings and breastfeeding supplies and support. If you are not in a grandfathered health plan (a plan already in place when the Affordable Care Act was enacted that has not been changed in certain ways) you will receive these benefits without co-pays.
Too many women have been faced with a policy that doesn’t cover maternity care. If, God forbid, something goes wrong along the way—they end up with an emergency C-section, or they have a baby who has complications and is in the NICU—it could mean bankruptcy. Beginning in 2014, most plans will be required to cover maternity care and millions of women will have peace of mind.
[Editors’ note: For more information on grandfathered plans, visit healthcare.gov]
Under the ACA, will families who already have insurance need to get new coverage?
If you like your insurance, you don’t have to do anything. Your coverage is not going to go away. But starting in 2014, if you’re shopping for coverage on your own, or you’re a small-business owner who can’t find affordable coverage for yourself or your employees, you’re going to have some additional choices. Insurance companies are going to operate under different rules for changing premiums and dealing with preexisting conditions. Each state will have what’s called an Affordable Insurance Healthcare Exchange that will accept applications, provide eligibility determinations for health benefits coverage, and provide a way to purchase health benefit coverage online. [Editors’ note: Consumers can log on, see what they’re eligible for, and compare plans.]
Earlier this year the Supreme Court ruled on the provision of the ACA that requires people to pay a penalty for not having health insurance; they found that it was constitutional and upheld the law. But it seems clear that if President Obama is not re-elected, the ACA will be vulnerable again. What’s the reality?
The President is committed to full implementation of the act. The other candidates [Romney and Ryan] say they want to repeal. How successful that could be, what that would look like, I really have no idea. We’re just looking ahead, assuming that the law will be fully implemented. [Editors’ note: We asked Robert Field, Ph.D., J.D., M.P.H., professor of health management and policy, School of Public Health, at Earle Mack School of Law at Drexel University, what it would take to overthrow the law, and how likely that is. “An out-and-out repeal seems unlikely,” says Dr. Field. “In order for that to happen, both houses of Congress would have to pass the legislation and the President would have to sign it.” Even if Governor Romney wins the election and Republicans take control of Congress, they’d be up against many passionate consumers who support parts of the law as well as lobbyists from drug companies, hospitals, and insurance companies who would fight to keep the new customers they’ve gained under the ACA. However, even if the law were not fully overturned, it might not remain intact the way it’s currently written. A Romney administration could do a lot to impede the full implementation. “Some of the parts of the law are discretionary, and Romney could decide to defund or under-fund them,” says Dr. Field. And though the ACA requires preventive care services to be provided without deductibles or co-pays, a Romney administration could redefine preventive care to exclude more controversial elements, such as contraception.]
What else is ahead that families should know about?
Right now, a lot of women can be charged up to 50 percent more for exactly the same coverage that a man has—even if that coverage doesn’t include maternity care—because the practice of “gender rating” is legal until 2014. But after that, insurers will not be able to charge women more for their health coverage.
Also, starting in 2014, no one can be denied coverage because they have a pre-existing condition. For women, a pre-existing condition could mean you’re a breast cancer survivor, you’re a victim of domestic violence, or you’ve had a Cesarean section in the past. Right now, insurance companies can refuse to insure you or refuse to pay for any kind of complication that may arise in the future from those circumstances. But those rules will change across the board. What I like to say is, “Being a woman will no longer be a pre-existing condition.”
People will also have more flexibility when it comes to leaving their jobs. I know women who work only for the insurance. They may hate their job, but they or a family member have a health condition, and they say, “I can’t leave.” Those choices will be a thing of the past. You will be reassured that, no matter the circumstance, whether you have a pre-existing condition, have difficulty paying for health insurance, or lose or change jobs, the law will help you get access to affordable coverage.
This brings us to a reader named Kristin Lupo, who asks, “Will the law help cover expenses such as groups or therapies for kids with autism or other developmental delays?”
Certainly there are some specific screenings for autism recommended by experts for children at a very young age that will be covered without any co-pay or co-insurance [in non-grandfathered plans]. The right services will be determined by the family and their health care provider, but the provisions in the Affordable Care Act will remove financial barriers for recommended services in behavioral health. And a young adult [a child under age 19] who has an autism diagnosis can’t be locked out of the market, and can stay on a parent’s plan until 26—as can any young adult without his or her own coverage—and will be able to fully participate in the insurance market, which isn’t an option now.
How will the act affect reimbursement for members of the military?
It doesn’t. TRICARE is the federal government’s program that covers the military and their families. The ACA affects private insurance plans, so TRICARE is not impacted in this.
This question from our reader Stephanie Dixon may sum up how many moms feel: “It seems like even people who think that the ACA is a good idea are very scared of how it’ll affect their family’s budget. Most of us, regardless of our political bent, are struggling. How will it help the average working-class citizen?”
We know that it’s far less expensive for a family and for employers to pay for preventive care than to pay the costs when people get sick. Families currently have co-pays, and pay out of pocket every time they get flu shots and every time they get their kids immunized. Under ACA that ceases to exist. Also—and a lot of people don’t know this—people who have insurance are paying for people who come into the emergency room and have no insurance at all. When an individual is uninsured and cannot afford to pay for care, the cost of that care is absorbed and passed on in the form of higher premiums to those who are in a position to pay, which drives medical costs up across the board. So having everybody with some coverage actually lowers the costs for everyone. In the two and a half years since the law has been passed, we are seeing the slowest rise in health costs that we have had in the last 30 years.
Is there anything else you’d like to get across?
We want to encourage people to use their preventive health services throughout the year. For example, October is Breast Cancer Awareness Month. We know that if breast cancer is detected early, the survival rate is close to 100 percent; the survival rate for late detection is closer to 23 percent. Between private insurance and Medicare, there’s no co-pay—there really are no financial barriers anymore. So get screened. [Editors’ note: For more information about breast cancer screening, prevention, diagnosis, and treatment, visit womenshealth.gov]
How does your role as a mother and new grandmother [to 13-week-old grandson] inform the work you do with healthcare?
A lot of things that were statistics on a page are now very meaningful to me. I watched my son and daughter-in-law plan for a baby, want to conceive a baby, have the experience of going to prenatal care, think about birthing, and use lactation-support services. Watching all of this up close and personal at every step along the way, I thought about how many parents would not have had that coverage if the ACA had not been passed and signed into law. We had gone to the Institute of Medicine and asked doctors, researchers, and experts to look at health plans and tell us what the gaps were for women’s services. A lot of health plans had no maternity coverage; a lot of women don’t even think about that until they get pregnant, and then it’s too late, so they’re doing it 100 percent out of pocket, or don’t get screened for gestational diabetes, or have to pay for infants’ immunizations. Now, 47 million women will have access to preventive services without out-of-pocket costs. That’s a huge deal.
For more about the ACA, including a timeline of what’s changing and when, visit healthcare.gov.
Editors’ note: This conversation was edited for space.Add a Comment