What’s in the ACA anyway? [Part 1]

It’s come to my attention that a lot of people in favor of repealing the Affordable Care Act don’t actually know what it says. And it occurs to me I’ve never read the thing either. So we’re going to fix that.

This is going to be a series, because the ACA is long. You can follow along at congress.gov, which offers a (very dry) summary and a (even drier) full text version. The goal here is to provide information, but of course, I will disclose up front I’m in favor of “Obamacare”.

(And yes, the ACA is the same thing as “Obamacare”.)

So without further ado, let’s dive right into the first title:

Title I: Quality, Affordable Health Care for All Americans

Immediate Improvements for All Americans

Catchy title, yeah? It comes right from the bill: “Subtitle A: Immediate Improvements in Health Care Coverage for All Americans”. This is stuff that goes into effect right away, from day 1, applying to your existing plan.

There’s a small caveat here: some plans were “grandfathered in”. But other than that, all plans have to abide by the following new rules:

  • No insurance plan can have a lifetime limit on the dollar value of benefits. This means even if you get cancer and spend tends of thousands of health insurance dollars, effectively losing the health lottery, they still have to keep covering you after that as long as you’re willing to keep buying the plan. Before, it was common for your health insurance to basically evaporate after a costly treatment plan. Of course, you could always change insurances… if someone was willing to cover your pre-existing condition.
  • No insurance plan can have an annual limit on the dollar value of benefits. This doesn’t apply to non-essential services; I have an annual limit on my dental plan, and a couple crowns knocked that right out, leaving me stranded paying for my own fillings for the rest of the year. Right now, that can’t happen to my health plan, but hoo boy will that be a problem if the law changes.
  • You can’t be dropped from your plan mid-year. The only way they can drop you from a plan without you cancelling it yourself is if you lie to them.
  • Preventative care is free. They define preventative care as anything rated A or B by the United States Preventative Services Task Force, which means the complete list is on the USPSTF website. This includes vision tests, cancer screenings, tobacco use interventions, and diabetes screenings. This is huge; it’s a necessary step toward improving the health of the general population and thus reducing the cost of care for everyone.
  • In the same vein, immunizations are free as long as they’re recommended by ACIP.
  • There is also a special line indicating that health screenings for women that are not otherwise recommended above are also free if they’re supported by the Health Resources and Services Administration. For whatever reason, regular gynecology appointments — long recommended for the overall care of anyone with a vagina — are not listed on the USPSTF website. This fixes that hole.
  • Dependent care for children under 26 is mandated in this section. If a plan covers dependents, they’re covered until age 26. The norm previously was to drop coverage for children when they turned 18, but that means people continuing in school have to buy your own insurance while they’re at university and thus probably not working full time. Many students chose to go uninsured, and many universities ended up supporting the burden of caring for uninsured individuals through their nursing staff or graduate students.
  • Standardized reporting of benefits. The Secretary of Health and Human Services was required by this bill to develop and maintain standards for what plan disclosure looks like, and every plan is required to disclose what is and isn’t covered to the policy holder before they purchase their plan. This was designed to make comparing plans easier.
  • Employers now cannot discriminate based on salary, offering better plans to their top management than they offer to their rank-and-file.
  • The act requires insurance companies to disclose whether they cover recommended practices. The health secretary is instructed to create a list of things that reduce the risk of hospital re-admissions, prevent problems like diabetes, or otherwise improve the general health of the populace. Once this list is developed, plans are required to tell you if they cover those practices or not, allowing you to choose the plan that’s likely to cover the things you need to avoid high fees in the first place. Again, this is designed to reduce the overall cost of care for everyone: the less hospitalization people need, the less crowded the hospitals are, for example.
  • This act, surprisingly to me, protects gun owners from being charged more by their plans, denied certain coverage, or even collecting information on whether you own a gun. I had no idea that was even a problem.
  • The act also caps the amount of money they can collect from you in premiums. This isn’t a hard cap of a certain dollar amount; rather, if they collect a huge profit over what they’re paying out, they’re assumed to be scamming the people and required to pay some of it back. The most margin they can collect is 20%.
  • Every hospital in the US has to publish a list of standard costs for various services that they provide. This allows people to comparison-shop on hospitals and avoid going to ones that overcharge.
  • Every plan is now required to have an appeals process that is fair; they have to tell you how to appeal in a language that is “appropriate”, and the process is subject to external review. Furthermore, if you appeal a claim, they still have to cover you while the appeals process is ongoing.
  • The act provides money for states to create consumer assistance boards to help consumers with their insurance needs. This includes educating you on your rights, helping you through the appeals process, and helping you with buying group insurance (such as the plans in the marketplace; more on that later).
  • The Health Secretary is also charged with reviewing premium increases to ensure that none of them are unreasonable. If your premium went up and you’re unhappy, that’s who to talk to: they literally get paid to prevent the premiums from rising more than they ought to.

So to recap: the act already has provided huge gains for improving the public health, reducing cost of health services, and bringing more fairness to the health insurance marketplace. The overall goal of this section is to reduce the runaway costs the American public has to shoulder, and bring us more in line with other first-world countries in terms of cost of care.

But we’re not done yet:

Immediate Actions to Expand Coverage

Subtitle B covers “Immediate Actions to Preserve and Expand Coverage”. Much of the bill goes into play on Jan 1, 2014; however, Congress was impatient for the coverage to begin, and created some temporary provisions that go into effect immediately to boost overall insurance coverage. These provisions covered:

  • Individuals with pre-existing conditions via a “high risk” pool. This not only offered coverage to people who couldn’t get it before due to their conditions, such as diabetes or MS, but also offered coverage to people whose employers encouraged them not to take their insurance benefits for fear of driving premiums up for everyone else.
  • Early Retirees were also given a pool and a chance to buy insurance again.

Finally, this act paid for healthcare.gov to be comissioned immediately, in advance of the plans being ready. We all know that turned out to be a fiasco, but the general idea of a website that lists out your options to buy online is sound, right? If you’re at all interested, there’s a great talk on youtube about why healthcare.gov was so awful and what we can learn from the running of that project. Software projects are very hit or miss, and healthcare.gov was all misses.

There’s nothing really interesting in this section for us now. Everything here is long over and done with. But I didn’t want to leave any part out.

Health Insurance Market Reforms

Subtitle C is properly called “Quality Health Insurance Coverage for All Americans”, but it has two parts: market reforms and everything else. This section is about bringing insurance to everyone, permanently, starting Jan 1. This is aimed at the 48 million people that didn’t have insurance (now only 29 million); estimates suggest 45,000 people died annually due to lack of insurance. So let’s keep that in mind.

  • Plans can no longer discriminate based on preexisting conditions. This is huge. I can’t stress how huge this is. If the ACA is repealed, I might not be able to get insurance because I have fibromyalgia. My father-in-law might not be able to get insurance because he has diabetes. People with cancer. People with asthma. People with heart disease. People with high blood pressure, or hay fever. Something like 27% of Americans, 57 million people, could never get insurance before this act. Now, health plans have to accept everyone who applies. If you like their product, and you like their price, you pay it and they cover you, end of story. They can’t charge you extra or anything.
    • The only exception is tobacco use. They can change more for smoking.
  • Plans are allowed to create wellness programs that help the populace get and stay well. This sadly often turns into size-based discrimination, but the amount of discount they’re allowed to offer is capped at 30%, and the plan must be offered to everyone and must be aimed at reducing the prevalence of a disease.
  • Plans are specifically prevented from discrimination against health care providers so long as the health care provider is licensed and so on.
  • Plans aimed at individuals or small groups have to cover certain essential health benefits. They’re not outlined here; we’ll cover them when we get to them. Similarly, company plans cannot exceed certain maximums, but they’re defined elsewhere as well.
  • Any plan has to offer a version that covers children only. This ensures that if a child has health problems their parents do not share, they can get more coverage than the parent. Previously, if your child had higher needs than you did, you had to upgrade to a “family plan” where both adults and children had higher premiums. This effectively cuts the cost of covering your child in half.
  • No plan is allowed to implement a waiting period of greater than 90 days. Unfortunately, 90 days is still a long time in the health world, but at least there’s a cap.

The “other reforms” here all refer to one basic concept:

  • The infamous “keep your coverage” clause is here. Just as Obama said, the act specifically states that you can keep your coverage. However, there’s a bit of a gotcha: it states that no part of the act can be read as requiring coverage to be dropped, but it doesn’t forbid insurers from deciding to cancel your plan out of spite anyway. But the act does call out that any existing plan does not have to be changed; that if you keep your coverage, your family can join you; and that if a company keeps their plan the same, you can still join in. No existing plan is required to be changed to uphold the law; new plans have to be created, but it’s your choice to take them.
    • Remember all those “grandfather plan” exemptions? That’s defined here: on the day the act was signed, any plan that existed was exempt from all the requirements of this act.

I think that’s where I’m going to stop for the moment. The next sections deal with the Exchange, which is a big topic to cover on its own. So far, however, there’s really nothing to be scared of. You can argue pros and cons of the tax parts, and the exchange bits, but the above? This is pretty much all good stuff.

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3 Responses to What’s in the ACA anyway? [Part 1]

  1. kaelas17 says:

    This is really great. I’ll admit that while I know I *should* know this stuff, I never had the patience to actually read through it. So… thank you for biting the bullet and breaking it down into tolerable sized chunks.

  2. Firedrake says:

    So why is gun ownership treated differently from tobacco use? Both of them are essentially voluntary lifestyle choices (there may be societal pressure, but nobody holds you down and forces you to do it) which have a significant correlation with adverse health outcomes.

    (I know the answer is “politics”, I’m just trying to make a point.)

    • yamikuronue says:

      yeah, the only answer I have is the NRA. To be fair, the point I’m trying to make with this series isn’t that the ACA is perfect, but that it’s nowhere near as terrifying as people make it out to be 🙂 It’s just… an ordinary law. There’s no sinister agenda here, just the usual amount of politics and bullshit, you know?

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