What does Alabama Senate Bill 20 say?

I got into a discussion today about Alabama Senate Bill 20, so I figured I’d do a piece on this bill in the same vein as the ACA ongoing series. The full text is available for this bill online as well.

This is a nice, short, concise bill. I’m skipping the synopsis because I don’t believe that part would be legally binding, and we’re keeping an eye out for loopholes here.

This bill amends the existing legislature Sections 22-9A-17, 30-1-5, 30-1-12, and 23 30-1-16 of the Code of Alabama 1975. It removes sections with the following effects:

  • The Office of Vital Statistics will record all marriages
  • A Probate Judge will prepare the form to give to the OVS
  • The officiant who performed the marriage will fill out and return the form to the judge within 30 days of the marriage ceremony
  • The judge must forward the completed marriage forms to the OVS on or before the 5th of each month
  • The entire current process for amending a marriage recorded in the above manner

If this bill becomes law, all of that ceases to exist. It is replaced with the following:

  • “the only requirement for a marriage in this state shall be for parties who are otherwise legally authorized to be married to enter into a marriage as provided herein.” This literally states that anyone who wants to be married can, provided they pass a few tests
    • The judge still gets to collect the same recording fee as before, though. This bill does not affect the civil costs of marriage
  • This bill creates a “marriage document” that contains the following:
    • Identifying information about both parties (as laid out elsewhere in existing legislature). I think this is a circular reference: it says 22-9A-6, but that just says that each document is spelled out below, and 22-9A-17 (the bit pertaining to marriages) is what’s being amended here.
    • The full legal names of both parties
    • A notarized affidavit (basically a legally binding statement) from both parties that states the following:
      • The person signing is not already married
      • The person signing is at least 18, or is at least 16 with parental consent
      • The person signing is legally competent (not under guardianship or something like that)
      • The parties are not related legally (with a reference to the laws that pertain)
      • The person signing is not being coerced
    • A signature from each party
  • A  marriage is valid as of the date it was “executed”, so long as the court is informed within 30 days. This appears to mean that signing the form makes you legally married.
  • A ceremony may be conducted. However, the state may not require that a ceremony be conducted.
  • The forms mentioned above are considered a “legal record of the marriage of both parties”
  • A copy of the form will be sent to the OVS
  • If there’s an error on the form, a corrected version may be filed, and the costs are the same as filing the original. The amended versions will say they have been amended, and the judge will file them and forward them to OVS. If the two parties disagree on what the amendment should be, they have to settle it in court.
  • This bill does not affect divorce, child custody, child support, or spousal support. (It says that right on page 10)
  • All requirements to obtain a marriage license are repealed
  • The requirement to hold a ceremony is repealed
  • The Alabama Law Institute will create a form to meet the needs above
  • This bill will take effect 30 days after it is signed

Other parts of the bill change parts of the existing legislature:

  • Parental consent for 16 year olds is still required, but the requirement changes to being an affidavit that is notarized and filed
  • Instead of keeping a record of marriage licenses issued, the judge now keeps a record of marriages recorded

And that’s it. That’s the bill.

Now for my editorializing: I think this is a good bill, on the face of it. The current concept of how marriage works is that the government checks if the marriage is legal, then issues a permission to get married (the “license”). Then, an officiant performs an actual ceremony; this officiant has to be registered with the courts, making the choices in many areas only consist of a clerk or a Christian pastor. Religious officiants often put extra requirements on the couple, like marriage counseling or religious tests; civil clerks require you to get married in a small ceremony at the courthouse, since they don’t usually travel. So it makes you conform to what is “normal” in your marriage ceremony. Furthermore, the law requires a ceremony; you can’t just decide to be married on your own, you have to have the big hoopla. Under this bill, you decide what you want the event of your marriage to look like, and then tell the court “by the way, we got married”. This is less burdensome to the couple, and allows for a wider variety of ceremonies — if you wanted to have a handfasting in your backyard, and you don’t have a Wiccan officiant, you would have to also go to the courthouse, and that courthouse visit is considered your “real” wedding since that’s the official date your marriage began. Under this bill, you just do it, and tell the court “we were married on X date”. It’s getting the government out of the business of legitimizing religious ceremonies, and I approve.

I hope that helps.

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What’s in the ACA anyway? [part 6]

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

Title III (continued)

Specific Medicare Part Reforms

Subtitle C: Provisions Relating to Part C” talks about reforms to Medicare Part C. Part C is also called “Medicare Advantage Plans”; it’s basically a private company subcontracting for Medicare itself, so that your Medicare benefits are actually served through this company. This section implements the following reforms:

  • (It’s the return of the bulleted list! Are you excited?)
  • For each market, the amount paid out is set to the average of the bids in the area. This could be problematic if they join forces to raise the bids, but that’s illegal I’m pretty sure, so they figure that won’t happen and it’ll keep the rate competitive. Plus the Secretary is asked to set up some rules to keep the playing field fair, so there you go, problem solved I guess.
  • But the plan does add performance bonuses for doing well at providing service, including paying out more if you save Medicare money and paying bonuses if you provide particularly high quality care or manage the care in a particularly efficient way
  • Plans are now forbidden from charging more to the beneficiary for chemo, dialysis, or nursing than the original Medicare plans would have charged, so they can’t save money by making it back from people with cancer and charging them more copays
  • If things are coded differently for these plans vs the original plans, the Secretary is tasked with adjusting the payouts to handle that. This I think is meant to reduce fraud?
  • It also provides a mechanism where you can quit your MA plan and go back to the original Medicare every year, between January and March. That way if your MA plan stinks, you can get out of it
  • The Special Needs Plans are extended, so those continue existing
  • A new type of MA plan is created that only applies to people in nursing homes
  • The Secretary is not required to accept any bid for a plan that would increase costs for beneficiaries or decrease benefits. I think this means those plans don’t get created if the bid isn’t accepted, so that the ones that are available are more likely to be fair.
  • The National Association of Insurance Commissioners is created

Subtitle D deals with Medicare part D: “Medicare Part D Improvements for Prescription Drug Plans and MA-PD Plans”. Part D is the part that covers prescriptions.

  • This section opens strong by instructing the secretary to create a program where people on medicare pay less for brand-name drugs, and spells out the incentives for manufacturers to partake (their brands won’t be covered if they don’t).
  • It also creates rules where widows get longer after their spouse’s death before they have to deal with the paperwork to re-assess their eligibility for medicare (1 year)
  • If and when the Secretary moves people around between plans, the ACA lays out the information they are required to be presented with so they can understand their new coverage
  • The plan allows the Secretary to define classes of drugs, such as antipsychotics or immunosuppressants, that are of particular concern to the overall health of the American people; all drugs in those classes must be covered by medicare part D
  • To pay for a lot of this, people who qualify for Part D but at a higher income level pay more in premiums
  • The Secretary is asked to enforce reforms in drug dispensing for long-term support care facilities to eliminate waste involved with 30-day refills
  • The Secretary is asked to create a complaint system to efficiently resolve complaints and retain the information associated with them
  • All sponsors of prescription plans have to provide a uniform appeals process with a toll-free number and a website
  • Drugs used to treat AIDS count toward the out-of-pocket limit

Subtitle E deals with “Ensuring Medicare Sustainability“. This funds a lot of the other reforms; first, it adjusts the costs of everything up to compensate for inflation, and secondly, it increases the premiums by income level. It also establishes a board to keep an eye on medicare spending over time. Weirdly enough, it also sets up a study to measure the quality of psychiatric hospitals; I guess those are expensive?

Subtitle F is back to “Health Care Quality Improvements“. It creates the following programs:

  • This funds the Center for Quality Improvement and Patient Safety to carry out research and create grants according to that research
  • It creates grants for establishing community-based interdisciplinary teams to support primary care doctors
  • It creates grants for medication management services for chronic illness
  • It creates grants for innovation in emergency care services
  • It creates grants for trauma centers on tribal lands
  • It creates grants for “patient decision aids” to help people make health care decisions
  • A study is funded for researching if better labelling of prescriptions would be useful
  • It creates an Office of Women’s Health to study women’s health needs

Subtitle G, “Protecting and Improving Guaranteed Medicare Benefits“, is one of those CYA protections: it states that nothing here can accidentally reduce benefits, and any money saved by the above measures goes right back into Medicare to increase the solvency.

And that’s the end of Title III!

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What’s in the ACA anyway? [part 5]

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

Sorry for the gap between parts. Self-care is really important right now, and as you well know, there’s been a lot of draining news coming from the Republican administration the past couple weeks. I’m still plugging away, but as the parts get longer, it’s going to stay fairly slow because I can only do it in small chunks. Stay well, and let me know if you’re interested in helping 🙂

Today we’re starting with “Title III: Improving the Quality and Efficiency of Health Care”. Spoiler alert: there are TEN titles. TEN. We’re on THREE. So this is going to be a long series.

Transforming Health Care

This section is all about “Subtitle A: Transforming the Health Care Delivery System”. This subtitle has three parts.

Linking Payment to Quality Outcomes

The first part is an effort to link payments made by Medicare to quality outcomes; in essence, you do a better job, you get more money. The first of these reforms is for hospitals: hospitals that do well with heart attacks, heart failure, pneumonia, surgeries (presumably reducing post-surgical infections, judging by the name of a previous act that this is expanding), and healthcare-associated infections (as in, you go to a hospital, you come away with an infection) get more money as an incentive. The exact details are left for the Secretary to come up with. The Secretary was commanded to make the details available at the Hospital Compare website, and also to make the overall website more accessible, since apparently it was pretty poorly designed at the time. There are also a few reports about hospital care commissioned by this act.

The next reform puts together some demonstration programs for value-based purchasing around inpatient critical access hospital services and for hospitals excluded based on not having enough case studies. This changes the way hospitals are paid by Medicare overall, so that they are paid based on the quality of care rather than the quantity of services. Furthermore, programs are established (a little later in the act) for value-based purchasing in nursing centers, home health agencies, and ambulatory surgery centers. I find myself at a loss to comment really, since I don’t understand the nuances of hospital billing, but the link above is a great place to start learning about it if you want.

The existing Physician Quality Reporting System was extended by the ACA, and more penalties were added for physicians not reporting their stats, so I guess that was working well.

Long-term care hospitals, inpatient rehabs, and hospice programs are a particular focus of the ACA, as we saw in part four;  here, they’re asked to start reporting quality metrics the same way physicians were, along with cancer hospitals. The Secretary gets to define what measures they report on.

Finally, the bottom quartile (so, worst 25%) of hospitals for hospital-acquired conditions (or, in essence, the ones that are the least clean and sanitary) get a penalty on their payment rates for procedures: they lose 1% of their fees for every patient coming through.

Strategy to Improve Health Care Quality

Part two is the “National Strategy to Improve Health Care Quality”, which is pretty straightforward. This isn’t particularly exciting; it’s all about putting up funds to create programs to actually do things, which is pretty much how the government usually works.

The first thing is the creation of the eponymous National Strategy, which you can read in its entirety at the link I provided. To summarize, the Secretary suggested:

  • Reducing the harm done in the delivery of care, such as hospital-acquired infections (1.7 million per year, costing $5 billion annually)
  • Improving communication and coordination between providers and patients
  • Ensuring that care is not only lead by the patient but also their family
  • Promoting effective treatments for common diseases, starting with cardiovascular disease (1 in 3 deaths, costing $500 billion annually)
  • Working with communities to improve healthy living
  • Making care more affordable

Yet another website is commissioned; for basically all the initiatives in the ACA, someone has to make a webpage explaining it. Better than the alternative, I suppose. Furthermore, a workgroup was created with members of 24 different agencies to create a holistic plan of action to streamline activities relating to public health concerns.

At least once every three years, the Secretary is asked to look over the existing quality measures and search for gaps where more attention is needed. They are able to create grants and government contracts to reward people based on these extra measures. A multi-stakeholder group  is set up to allow various interested parties to discuss and recommend quality measures to be implemented. And finally, the Secretary is charged with gathering reports and publishing them on a public website.

New Patient Care Models

The next part is “Encouraging Development of New Patient Care Models”. When the act was written, the best recommendations were incorporated and rewarded, to try and bring our care up to the current recommended level. But what about the future? This part allows for the creation of a Center for Medicare and Medicaid Innovation to test out new payment and service delivery models to see if they improve the standard of care. These models include:

  • Payment and practice reform for primary care, including centers that specialise in particular types of care
  • Using comprehensive care plans to coordinate multiple physicians for geriatric care
  • Using home-“telehealth” technology and a chronic disease registry to better treat people who are likely to need hospitalization
  • Rewarding doctors who use imaging technology by paying them more
  • Paying doctors more who use tools to help patients manage their own care
  • Paying more for hospitals who use the latest recommendations for cancer treatments
  • Allowing patients to coordinate their own outpatient care, such as physical therapy, without needing a referral

This part also includes the creation of a shared services program for Medicare . Best I can tell, this is meant to convince suppliers and providers to work together for the good of the patients, improve accountability, and encourage investment in infrastructure that both sides need. Basically, a bunch of medicare suppliers and providers get together in an organization, and if they report that they’ve saved money and become more efficient, they get money from the government as a reward.

The next program is a pilot on payment bundling. Okay so, basically, sometimes you have an incident and you have to go to the hospital, right? For the three days leading up to the hospital, the length of the hospital stay, and the month after the hospital, you’re likely going to need care for the whatever it was. This might include inpatient services, outpatient services, doctor visits, nursing, rehab, stuff like that. This program sets up bundles of services, so like, a torn ligament hospital trip plus the PT you need to rehabilitate after plus a few visits to a sports medicine specialist to check on how well the function is coming back might be one bundle, with one set price for Medicare to pay. They also would have to report a whole bunch of metrics about whether this helps you rehabilitate faster or better than someone who doesn’t have this bundle. I guess the idea is that people’s copays stack up and they drop out of the program.

There’s another program set up to determine whether a model that allows a physician and/or nurse practitioner to treat certain patients continuously at home would prevent hospital readmissions, reduce emergency room visits, improve health outcomes, and improve patient and family satisfaction. This is aimed at people with two or more chronic illnesses who have been hospitalized and who require help with basic necessities like dressing, feeding, and toileting. Rather than rely on untrained family members, having a nurse come by frequently might help reduce the overall cost of care if it reduces hospital visits.

Another program, called the Hospital Readmissions Reduction Program, penalizes hospitals that have “excessive” readmissions of patients, implying that they are not giving them good care to begin with. It also allows for the Secretary to create programs to help those hospitals reduce their readmission rates, and one to transition high-risk patients to non-hospital care. This last program specifically calls out Depression as one of the eligible conditions, implying that this can be a suicide prevention tactic; presumably, being release from the hospital prematurely after a suicide attempt can lead to a second attempt and hospitalization, while support groups and the like can help prevent relapse.

Finally, to help with the budgeting, the Deficit Reduction Act of 2005 is extended in the ACA.

Improving Medicare

The next subtitle is “Subtitle B: Improving Medicare for Patients and Providers”. Here we have, as before, three parts.

Access to Care

Part one is about “Ensuring Beneficiary Access to Physician Care and Other Services”. The first thing it does is tweak the calculations on how expensive a physician is relative to other physicians in the area, amending the Social Security Act that created Medicare. I think that means you’re allowed to see a more expensive doctor, but I’m not 100% on that; again, as with all the bits that amend other bits, I find myself at a bit of a loss to explain, as I am not a lawyer and have little understanding of what the previous amendments were.

The next few pieces have all expired: they extended a few existing exceptions to rules until 2010 or 2011. This includes paying labs directly when they’re being outsourced to from rural hospitals, paying for air ambulance rides in urban areas, and increasing the bonuses paid to ground ambulances. I have no idea if they were extended again or have totally expired.

They also allow a physician assistant who is collaborating with a physician instead of working under them to certify that a patient needs extended post-hospital care. This closes a loophole about who can sign off on the paperwork to make it easier to get care.

The next item offers more choice to vets and their families. This is a bit complicated, but essentially, Original Medicare has two parts: hospital-only emergency coverage (part A), and regular medical insurance (part B). There’s also something called TRICARE, which is available to military retirees, their spouses, and their children. If you are on TRICARE and eligible for Medicare Part A,  and you have declined part B, you get a year to change your mind and go on Part B.

The next item sets the payment for bone density tests to 70% of what it was in 2006, and commissions a study to look into the ramifications of doing so. I believe this is related to a 2009 recommendation that fewer women get the tests; my hunch is that medicare stopped paying for them around then, and this restores the coverage. I could be wrong here.

The Medicare Improvement Fund was defunded by this act.

Another demo project is created here as well, this one measuring a way to pay for complex lab services separately.

Finally, the payments for midwife services is increased to 100% of what a physician would be paid for the same service; previously, it was 60%.

Rural Protections

Part II: Rural Protections” must not exist, given Obama never did anything for rural white folks. I kid, I kid.

The first thing it does is extend an existing “hold harmless” agreement, giving extra money to hospitals who would receive less payments under the newer Outpatient Prospective Payment System than they did under the cost-based payment systems (up to 85% of the difference). Furthermore, it removes the 100-bed minimum for hospitals that are the only hospital in a given area to qualify.

The ACA extends a lot of existing agreements, actually. It extends an existing act that provides more reimbursement for small (under 50-bed) hospitals for clinical diagnostic laboratories. It extends and expands the Rural Community Hospital program to continue testing its effects on small rural hospitals. It extends the Medicare-Dependant Hospitals program, which adjusts payments for small hospitals who do most of their business with medicare. It extends and expands the Community Health Demonstration Project to pay more for hospitals that provide critical care but don’t get enough patients to keep them solvent on their own, and adds more payments for them for ambulance rides and outpatient care. It extends the FLEX program to pay for more preventative services at these hospitals. And finally, it establishes a program to study how well rural hospitals are being paid.

Payment Accuracy

Part III: Improving Payment Accuracy” starts out strong, commanding the Secretary to adjust payments for in-home services based on the average cost of providing care, as well as the number, type, and level of intensity of services seen in a typical episode. It also commands the Secretary to study and report on Medicare beneficiaries who are in “medically underserved” areas with varying severities of illness, and put together a program to help them.

The next few revisions are around hospice care: the Secretary is asked to study and come up with a plan to revise the way hospices are paid in a budget-neutral way. There is also a medical review requirement put in place for any hospice stay of over 180 days.

To reflect the lowered cost of acute hospital care, the price Medicare will pay for it is reduced in this act. The Secretary is authorized to reduce payments for other services if physicians are being overpaid, or increase them if they are underpaid. Generally, though, care costs have been skyrocketing, so it’s likelier to reduce the payments than increase.

The next bit gets complicated. Basically, when calculating how much use a hospital should get out of a specific imaging machine, like an x-ray machine, previously, the government assumed it was in use 50% of the time; half the session, someone’s using the machine. The ACA increases that to 75%, though only for high-tech imaging systems (meaning not x-rays or ultrasounds, but yes on fMRI and so on). This affects how much is paid for the imaging session, but I can’t tell if it goes up or down; most of the sources I’ve found assume you know how this is billed already. I think it goes up, because it pays for 45 minutes worth of machine use out of a 1 hour appointment? But I’m not sure. It also reduces the payout on second and third body parts you scan in the same session, because it doesn’t actually take that much work to set up the machine to run the same patient a few times compared to a few different patients, so they can’t scam the system by claiming the full price.

When purchasing power wheelchairs, Medicare is required now to pay in installments over time instead of in a single lump-sum, except for the most high-end wheelchairs.

There is some weird shell game involving temporarily reclassifying a hospital in a low-payment area as being in a high-payment area so it gets paid more; the ACA extends it.

The Secretary is charged with coming up with a plan to reform the hospital wage index. This appears to be a big index that spells out how much each type of physician in each area should be paid, so Medicare can tell if they’re being paid fairly or not.

There’s a study to see if cancer-related hospitals that do not qualify to be paid for inpatient services are charging more for outpatient services and, if so, what should be done about it.

For antibodies, enzymes, and other non-vaccine biological products, the ACA created a rate at which Medicare will pay for what is basically a generic version as opposed to the brand-name.

Another experiment is set up where patients who are in hospice can also receive other services under Medicare at the same time, to see if that’s effective. There’s another study commissioned to see if urban hospitals require more payment for inpatient services. And finally, there’s an extra protection for home health benefits, so that nothing here can reduce them on accident.

I was going to go further in this post, but I’m ill at the moment, ironically, and I want to keep forward momentum. So stay tuned for more. 

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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 congress.gov, 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 congress.gov, 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 healthinsurance.org.
  • 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 healthcare.gov 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 congress.gov, 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 Healthcare.gov, 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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