(Second of a two-part series on local effects of President Barack Obama’s Patient Protection and Affordable Care Act)
At its basic level, federal health reform, popularly known as Obamacare, is an attempt to enlarge the pool of insured Americans to help more people be able to afford health care.
It marks the first major advance toward universal health care, which has been promoted by leaders dating back at least to President Harry Truman, who served from 1945 to 1953.
While the Patient Protection and Affordable Care Act is far from the perfect solution to soaring health care costs, local experts say it is at least a good start. They encourage government, health care and insurance leaders to work together to repair the short circuits.
Although the idea behind the law's mandatory enrollment is often compared to car insurance because all drivers are required to have insurance, health care consultant F. Nicholas Jacobs says it is more like car insurance in reverse.
“With car insurance, the high-risk people are the young kids,” Jacobs said. “They are the ones having the wrecks.
“You need to have all the people who don't have wrecks to have insurance so we can pay for the young ones when they have wrecks.”
Jacobs was formerly president of Windber Medical Center. He works with hospitals and health care systems around the world as international director of Sunstone Management Resources of Pittsburgh.
Many young people traditionally have declined to buy health insurance because the chance is low that they would need expensive care, Jacobs explained. By requiring more young people to get insurance, it helps cover those with serious issues that require expensive care.
“No one has been able to get this (health reform) passed since Truman or even before,” Jacobs said.
“It finally got approved, but it is not a system the progressives or the conservatives would have liked. It is just a compromise; a hybrid that's just not pleasing a lot of folks.”
Dr. Matthew Masiello, director of the Center for Health Promotion and Disease Prevention at Windber Research Institute, called the Affordable Care Act an attempt to bring together two forces that are in opposition.
On the conservative side were those who favored letting the free market promote competition in health care control costs.
Progressives were pushing for a single-payer system, such as Truman’s proposal for national health insurance.
Dr. David Blumenthal, president of The Commonwealth Fund, saluted President Barack Obama’s success in getting the Affordable Care Act passed.
In a blog on the national health and social policy research philanthropy’ s website, Blumenthal noted the historic achievement that the Affordable Care Act represents.
“Until now, virtually every president who has dabbled with comprehensive health reform has failed spectacularly, often at huge political cost,” Blumenthal wrote.
“Think of Harry Truman’s lonely campaign for national health insurance, Jimmy Carter’s devastating conflict with the late Sen. Edward Kennedy over universal health care coverage, the first George Bush’s ineffectual (and little-remembered) health insurance proposal, or Bill Clinton’s damaging first-term effort to pass health reform.”
The need for reform is undeniable, Jacobs said.
“We are the only industrialized country in the world that is not taking care of our ailing people,” Jacobs said. “People are afraid to come into the hospital until it’s too late.”
Huge numbers are forced into bankruptcy every year by medical bills, Masiello pointed out.
Despite what he says was an inexcusable botching of the insurance marketplace rollout, Masiello believes the Affordable Care Act represents the nation’s best chance to provide medical care for its citizens into the future.
“If we didn’t have the technological mishaps, we would be on our way to have some type of health care that, at the very least, would be better than what we have,” Masiello said, adding he is worried about the consequences of a complete repeal.
Managed care organizations, through health care insurance companies, represented the market-driven approach to controlling costs and expanding coverage, Masiello said.
“The market driven approach to keeping costs down failed,” Masiello said. “Managed care hasn’t reduced costs or improved the health of our citizens.”
Masiello echoed Jacobs in pointing to what they see as the success other industrialized nations have had in bringing affordable health care to their populations. But many of those nations had glitches in the early stages, Masiello said.
“It has taken generations for some of these countries to get to a point where they can say they have health care for all, and nobody goes into bankruptcy because of their health,” he said.
Although Jacobs salutes the law’s push for preventive care and its plan to shift the paradigm toward reimbursing hospitals to keep people healthy rather than pay them to treat illness, he warns that the changes are going to be tough on the health care industry.
The shift began following Medicare changes approved during George W. Bush’s administration, but implemented under Obama. Medicare will no longer pay hospitals to treat infections in patients who acquire the infection during hospitalization, Jacobs said. They, likewise, won’t be paid for treating patients when they are readmitted within 30 days, he added.
“It is going to force quality to improve,” Jacobs said. “Those are all things that will benefit patients, but hospitals are running in circles trying to figure out how to stay open.”
The solution, Jacobs said, is in working with patients outside the traditional health care setting.
“It is going to require hospitals and health systems to engage the population that they serve at a grass-roots level,” Jacobs said. “Population health is going to be increasingly important.”
The idea is to pay providers to reach out and work with people to improve their lifestyles and reduce their risk for disease and injury, he explained.
“It should have been happening for years and years and years,” Jacobs said.
Health care plan basics
Here are some basics about the Affordable Care Act and how they apply to most citizens.
• Who is affected: Primarily those who don’t have insurance or who buy their own health insurance through individual policies. That’s about 20 percent of the population. The other 80 percent will see little effect because their insurance comes through their employer’s group plan or a government plan, such as Medicare.
• How to get insurance: Although individual policies are available directly from insurance brokers, those who qualify for government subsidies toward their premium must apply through the troubled healthcare.gov website. Help selecting a policy is available with newly created positions dubbed “navigators” who can help explain the enrollment process.
• What it covers: Just about everything. All policies under the Affordable Care Act must cover a set of benefits defined as “essential.” They include ambulatory patient service, emergency services, hospitalization, newborn and maternity care, mental-health services, prescription drugs, rehabilitative services and devices, lab services, chronic disease management, pediatric care and preventive and wellness services.
• Different types of policy: Out-of-pockets costs vary across four levels of insurance coverage defined in the law. Bronze policies cover 60 percent of average health care costs; the silver policies cover 70 percent; the gold cover 80 percent for gold, and platinum cover 90 percent. There also are stripped-down “catastrophic” policies for those younger than 30. For lower income families, there are limits on the out-of-pocket costs.
• Penalty for not buying insurance: A tax penalty of $95 will be levied on 2014 income tax refunds from those who choose not to buy health insurance.
• If it’s unaffordable: If there is no policy available that costs less than 8 percent of an individual’s income, the person is exempt from the requirement to by health insurance.
• Income levels for subsidies: Those making less than four times the federal poverty level are eligible for subsidies. That means an individuals making less than $45,960 can get some help paying for insurance. For a family of four, subsidies are available for those making up to $94,200.
• Deadlines: Open enrollment lasts until March 31.
• To preview costs before buying: Try thehealthsherpa.com, an independent comparison tool that shows available policies by ZIP code, with premiums, and also calculates individual subsidies.
The comparison tool on the government site, healthcare.gov, is working, but is a little more cumbersome.