Brief Interruption: Climate Change

I’m still working on the next ACA post. I just wanted to leave this here before it was purged from the internet on Trump’s orders:

National Park Services Report: Cultural Resources Climate Change Strategy

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What’s in the ACA anyway? [part 4]

Welcome back! We’ve gotten through the general reforms and are ready to tackle the exchange. As always, you can follow along at, which offers a (very dry) summary and a (even drier) full text version.

Public Programs

We’re on Title II finally: “Title II: Role of Public Programs“. This is talking about things like medicare and how it’s impacted (or not) by the new act.

Medicaid and CHIP expansion

We start off with “Subtitle A: Improved Access to Medicaid. The first thing this does is expand who has access to Medicaid. If you’re like me and always get confused, here’s the quick lowdown: Medicare is a program designed to help senior citizens who are retired still get the health care they need, while Medicaid is more like welfare in that it’s meant as a stopgap to help poor people. Under the ACA, anyone who is under 65 (because people over 65 get medicare instead), not pregnant (I think because CHIP helps pregnant women), and have incomes below 133% of the federal poverty line can sign up for Medicaid. In the ACA, this is clearly intended to be national, and in fact, is paid for by the federal government until 2016 to help bolster the costs. However, a Supreme Court ruling gave states the chance to opt-out, and many did.

The next provision expands the Federal Medical Assistance Program starting this year. I believe the result of this is that more money goes to the states, depending on whether they provide insurance to people at 100% of the FPL or not. Again, remember that under the ACA, having coverage means free basic health care: preventative visits of all kinds are covered 100% by the insurer.

This section also requires states to use the gross income to determine eligibility, as opposed to evaluating assets (like owning your own home) or anything like that. It requires medicaid to cover prescriptions and mental health coverage; I don’t know much about prescription coverage on medicaid, but mental health coverage has historically been very spotty and expensive. A lot of people can’t work because of mental health issues, and getting them help goes a long way toward reducing unemployment.

It also extends medicaid to cover foster care graduates until they are 26, the same as how a parent’s insurance can cover a child until 26. Foster care ends at 18; often, after “aging out”, the teens end up homeless,and only 6% attend college. Colleges are building programs to help improve that, but asking them to pay for health insurance on top of everything else would limit their usefulness. So medicaid steps in to cover at least that much.

(An aside: many people believe the church should be in charge of supporting the poor and needy. If you’re one of those people, I have to ask: what is your church doing to support the mentally ill, foster children, and others who traditionally fall through the cracks? The ACA doesn’t stop you from helping out. If it wasn’t necessary, I wouldn’t be as much in favor of it as I am.)

The rest of this covers more about how the federal government will reimburse the states: a credit for states going through a disaster, revisions on limits of the federal payout, and so on.

Having covered Medicaid, we move on to CHIP: “Subtitle B: Enhanced Support for the Children’s Health Insurance Program“. If you haven’t heard of it, CHIP is a program by which the states can cover children’s health insurance and the federal government reimburses them. The ACA isn’t the first time a democratic president has tried to tackle the health care crisis; in 1993, President Clinton and the First Lady made it a priority, but they were never able to get their reforms passed. The major thing that did get passed is this CHIP program, intended to cover children of parents who are working (and thus, under the old rules, ineligible for medicaid) but not making enough to buy health insurance. In 2007, it was discovered that many children were being dropped from their parents insurance because the employers stopped covering dependents, and the parents made too much to qualify for CHIP.

The ACA prohibits states from enacting more restrictive eligibility requirements than the ACA outlines. It offers money to states who enroll more children in CHIP, and it seems to be moving more children from CHIP to Medicaid. This is another section that’s difficult for me to parse, mostly because a lot of it’s corrections to other acts rather than explaining what it’s doing. You can read more about CHIP and Medicaid and the ACA in the Kaiser Family Foundation’s excellent summary.

Finally, in “Subtitle C: Medicaid and CHIP Enrollment Simplification“, we see reforms meant to make applying to these programs easier. It requires the states to maintain a website where you can apply for both medicaid and CHIP, and requires states to check if you qualify for any other assistance if they deny you the assistance you applied for, just in case you filled out the wrong form.The states are also mandated to do outreach to homeless youth, children with special needs, pregnant women, racial minorities, folks in rural areas, and people with HIV to inform them about the programs and help them get signed up. These are all groups with either a dire need for health care or who have been historically disadvantaged in purchasing it, so this is again meant to move toward a goal of 100% coverage.

Furthermore, if a hospital has a patient who cannot pay but who is probably eligible for one of these programs, they can treat them now and talk to Medicaid about paying for it after. That way if someone shows up at a hospital, they can walk away with a shiny new Medicaid card when they’re better.

Coverage Improvements

Now that more people are on Medicaid (and CHIP, and other programs like it), what can we do for them as far as covering more services? Turns out, a lot. “Subtitle D: Improvements to Medicaid Services” focuses on just that: offering more services under Medicaid.

The first thing that it covers is “freestanding birth centers” (and the ambulance ride to get to one if needed). This is defined as a non-hospital facility where someone has planned to give birth, so long as it’s licensed by the state and meets whatever requirements the state has  for this sort of thing. This basically gives women on Medicaid the freedom to choose a midwife over a hospital birth and still have everything covered. It’s all about choices here.

The next thing covers children in hospice care. It requires that, if the parents choose to continue treating the illness while the child is in hospice, that Medicaid cover both. Typically hospice care is reserved for those for whom no treatment is possible; however, under a new model called concurrent care, hospice-like services are provided to help ease the burden of care during treatment and improve treatment outcomes. This isn’t an area I have much experience or expertise with, but it seems like it’s a valid model of care here, so it’s nice to see more coverage options.

Finally, the controversial part: family planning services. This isn’t a mandate, but an option: states may choose to allow medicaid to cover family planning services. It’s pretty vague as to what that entails, punting the definition to the Social Security Act which just reads “family planning services and supplies furnished (directly or under arrangements with others) to individuals of child-bearing age (including minors who can be considered to be sexually active) who are eligible under the State plan and who desire such services and supplies”. I suppose therefore it’s up to the states to determine what to cover. If you’re curious, here’s a report on which states have chosen to enact this. I feel like we really ought to be holding states more responsible for their choices, rather than letting them point the finger at the feds, ya know?

The next section is “Subtitle E: New Options for States to Provide Long-Term Services and Supports“. These are all optional reforms, so it’s up to the states to decide if they want them or not.

The first expansion is home-based (or community-based) care for those who need assistance with their daily life. Previously, to get medicaid to pay for it, you’d have to move the individual to a nursing home; now, if expanded, it could cover someone to stop by every day (or week or whatever) and help out in the person’s own home. This also covers training on how to pick a good attendant, things like beepers so you can summon them when they’re not around and you need help, and transition assistance for moving out of a nursing home (first month’s rent, transportation, et cetera). It does not cover the attendant’s room and board, or any special education services. All 50 states offer some sort of home-based care assistance, but not all offer it through medicaid.

The act also expands and extends an existing program that was about to expire: the Money Follows The Person plan. This is a plan intended to help move people out of full-time care and integrate them back into the community, because full-time homes for the mentally ill and disabled are expensive, and much of the time the person would rather be integrated anyway. Why force people into care facilities to get treatment? For those who are staying in facilities, however, the act provides for the Secretary to come up with a plan to expand these centers.

Finally, we have another of those opinion bits where the Senate lectures about its findings to help express their intent. They point out that it’s been almost 2 decades since Congress looked into nursing homes, and that Congress never did act on the Pepper Comission’s report. They point out a Supreme Court decision that people with disabilities have a right to seek treatment in the community rather than going to separate facilities, and that since 1990 our nursing homes for elderly and disabled people have only gotten worse. 69% of Medicare funding for elderly and disabled people goes to these nursing homes, with half of states spending less than 25% of the funds for those groups on home care. They feel that Congress should address long-term support services for disabled and elderly people, and that services should be made available in the community as well.

Next we cover prescription drugs, in “Subtitle F: Medicaid Prescription Drug Coverage“. First, this makes certain drugs cheaper: drugs that induce clotting, and drugs formulated especially for children. It then amends previous acts to increase the rebate on…. something that I don’t know what it is, because this is another part that just amends a previous act without explaining what it’s doing. More importantly, it requires Medicaid programs to cover prescription drugs, and provide data about how they’re being used for future study.

It also appears to expand coverage to new formulations of existing drugs, such as an extended-release formula, and something called an “innovator multiple source drug”. I don’t know what multiple-source means, but an innovator drug is the opposite of a generic drug; usually, pharmacies call them “brand name” drugs. So this covers more of them.

Some drugs that were previously excluded from Medicaid are now covered: drugs to allow you to stop smoking, like the nicotine patch or the gum; Barbiturates, which are important for epileptics but are also addictive; and Benzodiazepines, which basically means Valium and Xanax and stuff like that. The reforms also allow the programs to pay out more for pharmacies that charge more than average, up to 175% of the average price of the drug.

The next subtitle helps pay for all this; “Subtitle G: Medicaid Disproportionate Share Hospital (DSH) Payments” reduces the amount available to DSH programs. Basically, when someone without insurance goes to the hospital on an emergency, can’t pay for their treatment, and gets to walk away without paying, this is the program that reimburses the hospital. With more people insured, the plan was to cut this spending in half, but it’s graduated based on how much coverage a state has achieved so that nobody gets left high and dry.

The next subtitle, “Subtitle H: Improved Coordination for Dual Eligible Beneficiaries“, creates a new government office: the Federal Coordinated Health Care Office. This office is meant to oversee the weird edge cases where someone is eligible for both Medicare and Medicaid, to make sure that people are still getting the care they need and not ending up in limbo.

Next up is the quality of Medicaid in general: “Subtitle I: Improving the Quality of Medicaid for Patients and Providers“. Previously, the Secretary was commanded to produce a report on recommendations to improve the health care of children; under this act, a new report is commissioned along the same lines but focusing on adults. $60 million is set aside to pay for this report.

The Secretary is also asked to review practices the states have enacted that prevent Medicaid from paying for conditions that someone picked up while in the hospital, such as a UTI that was transmitted via catheter. They are asked to turn the best practices into regulation for all the other states to use. More about this later, because this is the stick to a carrot established later in the act.

States are given the option of working with providers to establish health homes for individuals with chronic conditions, which Medicaid would then cover. This is for people with two chronic conditions, or one and the high risk of developing another, or serious mental illness requiring constant care. Asthma, substance abuse, diabetes, heart disease, and being fat are specifically called out as chronic conditions. 20 states have enacted this policy.

The Secretary is asked to  put together a “demonstration program” in not more than 8 states to show how states can bundle payments for people who are in the hospital and also receiving care from another provider. The goal is to reduce cost while improving the care for the patient. A second demo was requested to show how moving to a system where the payments for multiple patients are bundled together is more cost-effective than issuing single payments for each service. These reforms are just about reducing the overhead costs of Medicaid to be more efficient.

Another demo is aimed at giving some existing incentives to certain pediatric providers who were not previously eligible. Another is aimed at providing coverage for psychiatric emergencies handled at private institutions (rather than hospitals). We have a long way to go as far as effective psychiatric care, so this bit is more of an experiment to see if private treatment centers are effective in handling psychiatric episodes.

Another subsection we’re mostly going to gloss through: “Subtitle J: Improvements to the Medicaid and CHIP Payment and Access Commission (MACPAC)“. This commission, as well as MEDPAC for Medicare, is intended to study the ongoing programs and suggest improvements. This section of the ACA gives them some specific topics to study, such as enrollment and retention, quality of care, and regulations. They’re instructed to work with the states and MEDPAC, and to recruit people with experience as enrollees, caregivers, parents, and providers, as well as people recognised as experts in health finance, actuarial science, technology, and so on. The goal is to get a diverse team representing everyone from pregnant women to caregivers for disabled people, across all geographies, to generate recommendations.

Subtitle K: Protections for American Indians and Alaska Natives” is pretty much what it says on the tin.

Medicaid is usually the “Payer of last resort“, meaning that any other insurance an individual has pays out before Medicaid does; in this act, an exception is made for tribal insurance, making that the payer of last resort after government programs.

The “Express Lane” program allows Medicaid to let another organization such as SNAP, WIC, or Head Start to determine if you’re eligible for Medicaid; basically, if you qualify for food stamps, you qualify for Medicaid, in some states. The ACA allows Tribal Organizations and the Indian Health Service to count as Express Lane providers and tell Medicaid when someone in their tribe qualifies.

There was a previous requirement that the Secretary reimburse certain Indian hospitals for Medicare services; the ACA removes the expiration date on that requirement to make it permanent.

The last Subtitle in this section is “Subtitle L: Maternal and Child Health Services“. The first thing this subtitle does is concerned with early childhood visitation programs. It directs the states to assess the risks they face and identify what types of people are at risk for premature birth, low birth weight, infant mortality, and poor infant health. They are also asked to find communities that are impoverished, with high crime, high domestic violence, high rates of school dropouts, high substance abuse rates, and high risk of child maltreatment. They are then required to assess existing programs for early childhood visitation to determine who is getting visited, what gaps exist, and how well they provide for substance abuse treatment. They then have to turn in a report identifying the risks as well as a plan to fix them. I feel like this is a giant finger-waggle to the states, like the teacher’s upset nobody did the reading so they’re all expected to do a book report now. The upside is that there’s then grants made available to help pay for carrying out these plans.The rate of visiting drastically improved under this plan, so assuming that’s an effective way to prevent infant mortality, we should see good results.

The next topic covered is postpartum depression. The Secretary’s job is expanded to support basic research into the topic, as well as clinical trials for drugs treating postpartum depression and education campaigns to help people recognize it. This is a topic you don’t necessarily hear a lot about compared to all the joys of motherhood being discussed by new parents, but it affects up to 1 in 5 women, and only 15% of those women get treatment for it. Congress commissioned a specific report on the ways in which a pregnancy’s end (birth, birth plus adoption, abortion, miscarriage, stillbirth) affects postpartum depression; currently, the statistics gathered only count women who are depressed after a live birth. Grants are also made available for the states to enact programs to combat postpartum depression, but no specific programs are enacted in the ACA. A 2015 act follows up on this to provide more specific funding.

Next, grants are made available for personal responsibility education. This covers sex ed programs; it specifically calls out programs that teach both abstinence and basic contraceptive use, and programs must use evidence-based medicine, be medically accurate and complete, and emphasize both abstinence and contraception. In addition, to receive a grant, a program must also cover three of the following:

  • healthy relationships, such as positive self esteem, friendships, dating, marriage, and family interactions,
  • healthy attitudes toward body development, diversity, body image, and so on,
  • financial literacy,
  • parent-child communication,
  • educational and career success, such as how to job interview, live alone, and be productive in the workplace,
  • life skills such as negotiating, making decisions, setting goals, and managing stress

A separate, existing grant covering abstinence education is also extended, to pay for those programs.

Finally, for people aging out of foster care programs, the states are now required to educate them about the importance of having someone with health care power of attorney to make decisions if they were in a catastrophic health situation. Typically this would be your parents, but for people aging out of foster care, they might not have anyone legally capable of making those kinds of decisions.

And that’s it! That’s public programs. We still have quite a ways to go, however; next up is Title III, improving quality and efficiency of health care.

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What’s in the ACA anyway? [Part 3]

Welcome back! We’ve gotten through the general reforms and are ready to tackle the exchange. As always, you can follow along at, which offers a (very dry) summary and a (even drier) full text version.

So. Taxes.

Can I be real with you guys? It’s at this point in the project that I begin to lose my nerve. My eyes are bleeding a little bit from picking apart the language, and we’re about to embark on the worst part. But this is work that needs doing, and the inauguration is tomorrow (as I write this, it’ll probably be today by the time it goes up), and I need to do something. So. I’m going to finish. But I just wanted to let you in on how I’m doing.

Individual Tax Credits

This does little to improve my mood: “Subtitle E: Affordable Coverage Choices for All Americans – Part I: Premium Tax Credits and Cost-sharing Reductions – Subpart A: Premium Tax Credits and Cost-sharing Reductions”

(You guys. That says SUBPART. They have SUBPARTS now. Ye nelly.)

The first subpart is a tax credit. This is called the “Premium Assistance Credit”. It is calculated according to your household income, specifically how it compares to the federal poverty line. I broke my brain for a while trying to figure out how to translate the word problem that is the tax calculations, and then I went and found an article that explains it all pretty well.The general goal here is to reduce the amount you’re paying for insurance for low-income families.

It also adds a mandate for a study to be done five years out that determines how well this kind of tax credit worked. Which is pretty useful I’d think.

This subpart also outlines a cap to the maximum out-of-pocket expenses for people with low income. If your income is between 100% and 200% of the FPL, your out-of-pocket-maximum is only 1/3 of what middle-class people pay; if it’s between 200% and 300%, the maximum is halved, and if it’s between 300% and 400%, it’s two-thirds of the baseline.

It also raises the amount the insurer will pay for procedures; if you make between 100% and 150% of the FPL, the insurance company has to pay 90% of the cost of procedures, and if you make between 150% and 200%, the insurance company pays 80%. Combined with the above, this would basically mean if you pay for a Bronze plan, you get Platinum-level coverage. Which is pretty cool.

There’s a special rule for Native Americans, that they don’t have to pay anything for their health care (the plan covers 100%). They also don’t have to wait for an open enrollment period.

There is a section about how people who are not “lawfully present” in the country do not count as family members when calculating family size (used in calculating what the FPL is for your family size), and they are exempted from the above benefits for the poor.

Subpart B is all about how to determine who qualifies for the above. It outlines the information you need to present, but punts to the Secretary to set up the actual procedure for submitting the info and validating it. There’s also information about how if you apply for the Exchange and you actually qualify for Medicaid, the program should send you over to Medicaid and get you enrolled there instead. The same applies to CHIP programs designed to cover children.

Subpart B also sets up a study to see if the FPL needs to be modified on a region-by-region basis. A salary that would let you buy a house in rural Kentucky would leave you homeless in NYC; the federal poverty line is a country-wide minimum, but it might not be a good indicator of poverty in a specific region.

Small Business Tax Credits

Then we reach Subtitle E: Part II: Small Business Tax Credit. This is a separate tax credit for small businesses. Any business with fewer than 25 employees and who pays an average of $50,000 or less per employee qualifies for a 50% reduction in the health care costs of insuring their employees. This makes health coverage more affordable for small business owners, increasing the number of employees who get coverage through their work.

That concludes Subtitle E. As you can see, it does quite a bit to make health care more affordable for those who often fell through the gaps: the poor, and those working for very small businesses. The Exchange already covers those who are self-employed, which is the third gap you usually hear about.

Shared Responsibility

Now on to Subtitle F: “Shared Responsibility for Health Care”. This is the flipside, the stick to the carrot, the great responsibility that comes with great power. This has two parts; the first is “Part I: Individual Responsibility”, otherwise known as the “individual mandate”.

Individual Mandate

This mandate is justified as a federal edict by stating that it is a commercial, economic requirement that affects interstate commerce. The following justification for the mandate was provided within the act:

  • National health spending is 17.6% of the economy, at $2.5 trillion per year
  • National health spending was projected to increase to $4.7 trillion per year by 2019
  • Private insurance companies spend $854 billion dollars a year
  • Drugs and medical supplies are shipped between states, making this an interstate issue
  • Furthermore, most insurance companies serve an area larger than one state, making this an interstate issue
  • The requirement was projected to add millions of new consumers to the health insurance market, increasing the demand for health care services and supplies
  • 176 million Americans already had insurance; the goal was to achieve near-universal coverage. Today we have almost 319 million people, so that’s a massive increase in coverage.
  • A similar system in Massachusetts, upon which this act was based, increased the coverage percent even during the economic downturn. They didn’t give numbers in the act though.
  • Half of all personal bankruptcies were caused in part by medical debt. That’s right there in the act. Half.
  • They cite two other acts as precedent for the federal government regulating health care: the Employee Retirement Income Security Act of 1974 and the Public Health
    Service Act
  • If there were no mandate, people would wait to buy insurance until they were sick, which destroys the concept of a group pool: having enough premiums from healthy people to cover the people who are sick.
  • Administrative costs make up 26-30% of the premium costs, at $90 billion per year. By putting people into fewer, larger risk pools, that cost can be reduced.
  • Finally, the Supreme Court ruled that insurance is interstate commerce and thus regulated by the federal government.

So what does the mandate consist of? Any individual who does not maintain the “essential coverage” that is the core of any real insurance plan is subject to a penalty on their taxes. This penalty is a flat $750, and nobody can be charged more than three times that amount (so if you have six kids and none of them have insurance, you’re capped at paying $2250 instead of $4500).There was a phase-in period where it slowly raised, but as of 2016, the full penalty applies.

But this penalty doesn’t apply to everyone. Here’s a list of exemptions built in:

  • Individuals who belong to a religion recognised as having a conscientious objection to the mandate. There is an existing list of religions that are exempt from medicare and social security, and they object to the ACA on the same grounds. These religions must have existed in 1950, and they have to have a history since then of providing food, shelter, and medical care for their members. This includes the Amish and the Mennonites.
  • Individuals whose religion mandates that they have their own insurance pool and pay for each others expenses already. You can find more about these special plans at
  • Individuals who are not legally in the country
  • Individuals who are in prison
  • Anyone for whom the premiums would be more than 8% of their annual income, because they therefore cannot afford insurance.
  • Anyone under the federal poverty line, for the same reason
  • Anyone in a Native American tribe

The rest of this section outlines how the coverage will be reported and so on.

Employer mandate

Part two, “Employer Responsibilities“, covers the other side of it: what employers have to do to help reach the goal of full coverage. Employers must:

  • Automatically enroll all new employees in health insurance, and give them a form to opt-out. This only applies to companies with more than 200 employees, but it basically turns the system from opt-in to opt-out
  • Inform new employees about the health insurance coverage available when they are hired.
  • Offer coverage if they are a large employer. There is a penalty mandated that scales with the number of employees, but it only applies to employers with more than 100 employees (on average in any given year).
    • By the way, states are allowed to decide that a large employer is one with more than 50 employees if they prefer. Yay federal/local weirdness.
  • Cover employees within the first 30 days or pay a penalty for having an “excessive waiting period”. It’s a higher penalty if they don’t start coverage for 60 days. I’ve seen many jobs where you’re not applicable for coverage for the first 90 days of probation, so this is kind of a big deal.

Furthermore, a study was funded to investigate if this ends up with employers reducing overall employee wages.There are also reporting requirements laid out here. It’s also spelled out that if an employer is offering coverage through the Exchange, they’re exempt from the usual requirements to provide their own plan.

Other Stuff

Finally, we’re at the last section of Title 1: “Subtitle G: Miscellaneous Provisions“. This is the random assortment of other things added to encourage coverage for all Americans (remember, that’s what this Title is about: Quality, Affordable Coverage for All Americans).

  • The Secretary has to publish on the Internet a list of all the things they’re now responsible for doing, for transparency reasons
  • No health plan can discriminate against those providers who don’t offer assisted suicide
  • No regulation can be created that:
    • makes it harder to get medical care
    • interferes with communication or full disclosure between the doctor and the patient
    • violates the principles of informed consent
    • limits how much care you can get
  • Nobody is forced to participate in any federal insurance plan. I’m not sure what counts here, because the federal government isn’t creating the plans?
  • There’s an alteration of an existing law about survivors of Black Lung to make it easier to get payouts from that law. This is a law that offers monthly payments to survivors who got the disease in our country’s mines.
  • This act is specifically called out as not allowing anyone to violate existing nondiscrimination laws. This covers discrimination based on race, color, national origin, sex, age, and disability.
  • There’s also some wrongful termination stuff here: you can’t be fired for receiving a credit or subsidy from this act (aka “being poor”), reporting a violation of the act or testifying about it (aka “whistleblowing”), or objecting to any job duties that would violate the law (which would protect HR individuals who are being asked to break the law)
  • The Inspector General of Health and Human Services is given oversight over the act
  • Nothing in the act can be construed to interfere with existing antitrust laws
  • Hawaii’s Prepaid Health Care Act still stands and is not overridden by this law
  • Universities are still allowed to offer health coverage to their students
  • Rules are laid out for the internet stuff: how secure it has to be, how people’s identities have to be verified, how much money will be offered as a grant to pay for it. Again, we’ve all see now.
  • There’s a whole bunch of amendments to previous acts that this act would have been violating, to make them all play nice together
  • The Comptroller General is instructed to review denials over time

The last thing in this section is the “sense of the Senate”, which appears to be what the Senate hopes to gain from the act, like a business goal in a project plan. They feel that:

  • The deficit will reduce by 2019
  • Medicare will become more solvent
  • Social Security will have more surplus; the senate is not allowed to waste that on something else, but has to leave it in Social Security
  • the CLASS program will pay for itself; the senate is not allowed to spend that money on anything else either

And that’s Title 1. Looking over the list of benefits, I honestly have to wonder if the Republicans will bother about the parts that aren’t as publicised? They don’t have a plan yet; will they just throw something together and let everything else slip through the cracks?

You might be assuming now that we’re done, or almost. We’ve covered the general improvements, the new plans, the exchange, the mandate. That’s all the bill, right? Well, you’d be wrong. Stay tuned for Title 2: The role of public programs.

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What’s in the ACA anyway? [Part 2]

Welcome back! We’ve gotten through the general reforms and are ready to tackle the exchange. As always, you can follow along at, which offers a (very dry) summary and a (even drier) full text version.

Today we’re talking about the exchange. Obama called this out early as being akin to what Congress already had for themselves:  a one-stop shop for healthcare, to make sure everyone knew what was available. This was originally designed to be a single federal exchange, with a single-payer option provided by the government to help anchor prices and prevent collusion, but the Senate refused to ratify that. You’ll remember, the Republicans are very much in favor of states rights, and insisted that all states be able to run their own exchanges how they like, without the federal government getting involved in either a national exchange or a single-payer system. Their alternative to a federal exchange is allowing state exchanges to sell across state lines, giving you 50 marketplaces instead of 1.

Anyway, that’s enough of theory for the moment. On to the act!

Qualified Health Plans

This section’s title is “Available Coverage Choices for All Americans – Part I: Establishment of Qualified Health Plans”. Now, when legal language such as an act talks about “establishing” something, what they mean is really “defining what it is”. So this is the definition of what plans can be sold at the exchange.

To be sold in a state exchange, plans must:

  • Offer a silver plan and a gold plan. There are four categories of plan: Bronze, Silver, Gold, and Platinum. You have to at least offer the middle two options if you want to participate.The categories are based entirely on how the payment is split up, with Bronze being 60-40 (as in, you pay 40% of the costs), Silver being 70-30, Gold being 80-20, and Platinum being 90-10. In addition, deductibles go down as you go up the ladder. However, premiums go up as you go up the ladder. I suppose they figure most people will want one of the middle options, so that’s where the most choice should be. The deductibles and premiums are set by the insurance company, but the level of coverage is set by the act itself.
  • Cost the same as they would if you bypassed the exchange. This is a no-brainer; you can’t charge people extra for using the exchange or it’ll never work.
  • Offer a child-only version, as we discussed in Part 1.
  • Offer essential health benefits. We talked about this in Part 1 also; it’s defined here. In order to be offered on the exchange or to private individuals, plans must cover, at minimum:
    • Ambulances
    • ER visits
    • Hospitalization
    • Maternity and newborn care
    • Mental health
    • Prescription drugs
    • Rehab
    • Lab services, like bloodwork
    • Preventative services
    • Chronic disease management
    • Pediatric care
  • The Health Secretary will also define other essential benefits to be updated as time goes on. The law doesn’t care to define everything itself, but the above are considered the bare minimum of what you have to cover to be a health insurance plan and not some elaborate scam.

Then there’s some general improvements here, that only apply to plans offered on the Exchange:

  • The maximum deductible is capped at $2,000 for an individual and $4,000 for a family.
  • The out of pocket maximum appears to be capped. I am not 100% sure I’m reading this right, so I’ll paste the relevant section here in case I misinterpreted:
    (A) 2014.--The cost-sharing incurred under a health 
                    plan with respect to self-only coverage or coverage 
                    other than self-only coverage for a plan year beginning 
                    in 2014 shall not exceed the dollar amounts in effect 
                    under section 223(c)(2)(A)(ii) of the Internal Revenue 
                    Code of 1986 for self-only and family coverage, 
                    respectively, for taxable years beginning in 2014.

    If I read this right, and understand correctly what they mean by “cost-sharing”, this means you cannot be charged more than what you can contribute to an HSA in a year. Meaning if you have a HSA, you don’t need to chip in any extra. Of course, HSAs are hard to get (you have to have certain kinds of plans to qualify), but that’s pretty neat.

  • The act also created an extra category for emergency-only coverage, or “catastrophic coverage” in their terms. If you’re under 30,  you can choose to roll the dice, covering your own routine care but having coverage in case of emergency.

Then finally we have “special rules”. These are all regarding a particular hot-button issue: abortion coverage. They’re surprisingly fair:

  • Plans are not required to pay for abortions. It’s written right there in black and white: regardless of whether public funds are allocated, no plan is forced to cover abortion. Abortion can never be considered an “essential service”.
    • States are allowed to require that plans pay for abortions, but if they do, no federal funds can be used to pay for those plans in any way, shape, or form.
  • States are required to ensure that in their exchange, at least one plan covers abortion, and at least one plan does not. That allows people to choose a plan based on their own feelings about abortion. Because of the way these plans group people into a purchasing block, this allows people to verify that their premiums don’t pay for anyone else’s abortion if they’re against abortion. It also ensures that people who want an abortion can have one if they choose.
  • There is no discriminations against providers based on whether they do or do not offer abortions. If doctors aren’t comfortable performing abortions, they’re not allowed to be dropped from a network based on that. If they are, they’re not allowed to be dropped for that, either.

In short, aside from the abortion stuff, this is all pretty boring to us now, in 2017. We all have had a chance to see, read through the plans presented there, and understand what the coverage looks like. If you haven’t taken the time to do so, please do; there’s some good information there aimed at helping people understand what is and isn’t covered by each plans and estimate how much they’ll pay.

The Exchanges Themselves

Now we’re looking at “Part II: Consumer Choices and Insurance Competition Through Health Benefit Exchanges”. This is where the exchanges are formally created, now that we have plans to go in them.

  • States have to create an exchange where individuals can buy insurance. Federal money is granted to them for this purpose.
  • They also have to make one for small business owners to buy insurance for their employees. This can be the same exchange or a different one.
  • The Regulations Secretary has to create guidelines the exchanges obey, and ensure that they obey them. This is where we get into the downside of having 50 exchanges: someone has to oversee them all and ensure no state is cheating their residents out of their share of the act.
  • The bare minimum requirements in the act itself are that an exchange must:
    • be run by the government or a nonprofit
    • not offer any plan that doesn’t meet the requirements above
    • certify whether plans meet the guidelines or not
    • require insurers to justify any premiums increase they have in a given year
    • offer a website
    • offer a toll-free hotline to help people understand the website and plans
    • present all plans the same way so you can compare easier
    • offer a means calculator to help you figure out what your actual costs are
    • offer some way to certify that you are exempt from the tax penalties defined later on (for bookkeeping purposes, so the federal government doesn’t have to do it)
    • be self-sustaining, probably by charging insurance companies for certification
    • publish on the website how much it charges for various services to pay for itself
  • States are allowed to mandate higher minimum standards than the act itself puts out, but they are not allowed to lower the standards. If they require additional benefits be offered, the state has to pay for it, since there won’t be federal funding available.
  • Exchanges are already allowed to cross state lines. The only restriction is that both states have to agree to allow the exchange to operate, and so does the Secretary who regulates them. I had no idea! So the existing bill is already more in favor of states rights than the proposed replacements?
  • States are also allowed to have more than one exchange if they feel that different regions need different exchanges.
  • The Secretary is allowed to reward States for meeting goals like improved enrollment, reduced medical transcription errors, or decreased prevalence of a given illness.
  • Money is also set aside for paying people to help people use the exchange as long as they stay impartial and speak the appropriate languages.
  • Rather than offer their own plans, employers are allowed to send their employees to the exchange. Effectively, how this works is that employers say “Pick out any plan of X level and I’ll pay Y% of it”
  • You are not required to buy from the exchange. Companies are still allowed to sell you insurance the old fashioned way.
  • You are allowed to buy any plan in the exchange.
  • Effectively, everyone buying insurance from the exchange is treated the way employer insurance treats everyone in the company: as a single “risk pool”, where the premiums collected from everyone pay for everyone’s coverage before the company determines profit. Every small company is treated as a separate risk pool, but it could be the same risk pool as individuals.
  • You must live in the state whose exchange you buy insurance from. Kind of a no-brainer.

Part 3, “State Flexibility Relating to Exchanges”, gives the states extra flexibility, benefitting those states who can’t get an exchange up and running rapidly:

  • If a state cannot have their exchange running by Jan 1 2014, the Secretary can set one up for them to cover until they get it running
  • If a state already had an exchange, that exchange is assumed to be “good enough” and they don’t have to build another one

It also allows the creation of a grant to assist nonprofits who want to offer health insurance plans. The list of awardees is available on their website; however, two years in, over half of them had closed down. Part of this is due to policy: the law forbids them from using the federal funds on marketing, for example, which makes it difficult, because without marketing you have trouble getting donations to grow. Another challenge is that the final budget was cut by two thirds from the initial proposal. Finally, all that “you can keep your current plan” talk led people to, ya know, keep their current plan, meaning less money went to new plans.

(For all the Republicans talk about people not getting to keep their plans, about a quarter of people who get their plans through their employers kept their grandfathered plans.)

The next section, “State Flexibility to Establish Alternative Programs“, gives the states more options outside the exchanges. Firstly, it allows for a basic health program to be created if the state so decides. Two states have done this: New York and Minnesota. This creates an alternative option for the poor; in New York, to be eligible you have to be below 200% of the federal poverty level. It’s essentially an expanded version of Medicaid that the states run with federal oversight.

This section also outlines a process where states can apply to get out of some requirements, in case they think of something better later. And finally, it expands upon a point I noticed earlier: states can already cooperate to make mutually beneficial exchanges, or (in this section) to allow one plan to be in as many exchanges as the states care to approve.

The final section in this subtitle outlines how the state and federal funds will be allocated to help offset the money lost by insuring high-risk individuals. In essence, because people who were considered too risky to insure before are now required to be insured, the government will supply money to the insurance companies to cover their losses on the high-risk individuals. This is called “reinsurance”: insuring the insurance companies. Again, I’m not 100% sure I understand this concept fully, but it seems to be a way to help pay for the risks so that everyone can become more healthy overall and we stop having such high-risk individuals going into debt and overtaxing the ER systems.

And that’s it! That’s the section creating the exchange. That’s sort of pillar two of this ACA; we’ve talked about the general reforms that benefit everyone, and we’ve talked about the exchanges that allow people to buy insurance. Stay tuned for part 3, where we’re discussing the third major pillar of the ACA: the tax parts that fund the act.


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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, 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 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 was so awful and what we can learn from the running of that project. Software projects are very hit or miss, and 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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Senator Rob Portman: Bald-faced liar. (an open letter)

Dear Rob Portman,

As you know, I wrote you with my concerns about health insurance recently. As you are no doubt aware, you replied with a form letter full of vile lies that insult my intelligence. Let’s go through them, shall we?

The first thing you told me, after the opening pleasantries, was the following:

Before diving into the specifics of what I expect to see in law’s replacement, please know that I support a transition period that would maintain premium subsidies and Medicaid coverage through at least 2017 in order to ensure that all affected individuals will have due time to adjust to the new system and that no one loses coverage unexpectedly.

This is technically true; you supported an amendment that would offer more time to decide on the replacement measures. But you didn’t stand by the values you supposedly hold; you rescinded the amendment without much fanfare or argument.

The third paragraph of your email is the point where you become a liar. You write:

With the intention to better serve the people who have been disadvantaged by the President’s poorly conceived law, I have assembled a few key ideas that would be central to a new and improved healthcare system.

I was eagerly awaiting your contribution. And yet, this was all you had to offer me:

Most importantly, we need reforms that will make healthcare in the U.S. more patient-centered and consumer-driven. Such reforms could include enacting important consumer protections in the insurance market, like prohibiting lifetime limits on coverage and requiring insurance companies to cover dependent children up to age 26. A consumer-driven healthcare system would also include protections for individuals with pre-existing conditions so that they may not be denied coverage as well as a refundable tax credit targeted to certain individuals solely for the purchase of health coverage.

Look at what you offered me. You said that you wanted to prohibit lifetime limits on coverage. This is already in effect: as part of the ACA you voted to repeal. You are the one endangering me by introducing lifetime limits, not Obama.

You said that you wanted to require insurance companies to cover children up to age 26. Again, this was part and parcel of the Affordable Care Act that Obama signed, that you voted to repeal. You offer protection for people like me, living with pre-existing, chronic, incurable conditions — and a mere two days later, you voted to remove those protections.

You wrote:

After six years of the status quo, it is clear now that health care costs have grown out of control for many Ohioans

The thing that’s “quite clear” to me is that you are a two-faced liar, willing to sacrifice your constituents on the altar of party ideology. You should be ashamed of yourself, Senator Rob Portman.

By now you might be wondering why I’m calling you out by name, over and over, in this blog post. It’s simple. I intend to share this post as far and wide as possible so that everyone knows what your true colors are.

Who is willing to help me?

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Other: Please Specify

I changed the name of my blog. I never much liked “Raven Wings”, but I didn’t have anything better; it’s not like my posts are all on a theme or anything.

But my life kind of has a theme, if I squint real hard. I don’t quite fit into the neat boxes they put on forms for any of the standard questions: race, gender, sexuality. So I named my blog after the option I always end up checking: Other (please specify).

This blog is kind of my attempt to specify.

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