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A deeper look into Obama's affordable care act

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Dr. Todd Goldberg Dr. Todd Goldberg
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Dr. Todd Goldberg is an associate professor of geriatric medicine at West Virginia University, Charleston Division, and medical director of Heartland of Charleston and Edgewood Summit Retirement Community in Charleston.

Since "Obamacare" (officially known as the Affordable Care Act, or ACA) was upheld by the U.S. Supreme Court in June 2012, and President Barack Obama has been reelected, it appears that contrary to whatever anyone may have preferred, Obamacare is now definitively the law of the land. At least until things change again! But in any case it behooves us all in the medical, legal and political communities to understand exactly what is contained in this complex bill.

The Patient Protection & Affordable Care Act of 2010 was signed by President Obama on March 23, 2010, after almost a year of debate. Its more than 900 pages contain many complex provisions phased in over a period of 10 years. Some of the most significant provisions, by year, include the following:

2010: No one with preexisting conditions can be denied insurance. New policies cannot include lifetime dollar limits on essential benefits. Insurers can't drop customers once they get sick. Dependents (children) can remain on their parents' health insurance until age 26.

2011: Insurers must spend 80-85 percent of premium dollars on health costs and claims or rebate funds to the policy holders. Insurers must also notify the public before any rate increase of 10 percent or more. The Center for Medicare and Medicaid Innovation was established.

2012: Tax reporting changes. All new plans must cover preventive services as of Aug. 1 without deductibles or copays (e.g. mammograms and colonoscopies). Effective Oct. 1, CMS may reduce payments to hospitals with "excessive readmissions."

2013: Tax increases, followed by 2-3 percent across the board cuts under the "sequester" exclude Medicare. Pre-tax contributions to flexible spending accounts capped at $2500 per year.

Jan. 1, 2014: Full implementation of ACA including the individual insurance mandate and health insurance exchanges. Employers with more than 50 employees will be required to offer health insurance or pay significant financial penalties ($2,000 per year per employee). Annual spending caps are prohibited. Each state will offer consumer health insurance exchanges or the federal government will do so. A variety of plans may be offered but all must cover certain "essential health benefits." The website www.healthcare.gov is already up and running. Most Americans will be required to document they have insurance, probably on their tax return, by virtue of a tax penalty if they do not have an approved plan. (You will not go to jail and get free health care there if you don't have insurance!)
There will be certain poverty and religious exemptions. Members of Congress will choose their insurances through the same exchanges as everyone else rather than their current government-provided plans. Everyone up to 133 percent of the poverty line can be covered by Medicaid, subject to state implementation. Subsidies or discounts on health insurance via the exchanges will be available for households with income up to 400 percent of the poverty line. A controversial "Independent Payment Advisory Board" will attempt to restrain Medicare and Medicaid spending beginning 2015.

Also in 2015: CMS will give larger Medicare patients to physicians who provide "higher quality care."
By 2016, states will be permitted to form "health choice compacts" allowing insurers to sell policies in multiple states. Also, the threshold for itemizing and deducting medical expenses on your income tax increases from 7.5 percent to 10 percent for seniors.

By 2017, states may apply to the Secretary of Health and Human Services for "waivers for state innovation" allowing variations from the standard requirements of the ACA. Large employers and health plans will be able purchase coverage in the exchanges. Multi-state health plan (MSP) insurers will be available to all states.

2018: All existing health plans must cover approved preventive care and checkups. A 40 percent excise tax on high cost ("Cadillac") insurance plans will be introduced.

2019: Medicaid will extend coverage to former foster care youths up to age 25.

By Jan. 1, 2020, the Medicare Part D coverage gap (the "doughtnut hole") will be phased out.

With regard to Medicare specifically, with the main focus on expanding coverage to the uninsured, there were only a few small changes in Medicare include reducing the Part D "doughnut hole" and adding an "annual wellness visit." It is unknown at this juncture what effects the IPAB will have since it has not begun to function yet and there is a great deal of pressure to eliminate or water down its powers. Medicare alone comprises a full comprises 12 percent of the national budget, and public sources are estimated to pay for over 50 percent of the nation's $15 trillion health care bill. So in reality despite criticisms of both "corporate" and "socialized" medicine, the fact is the government actually already controls a majority of our supposedly "private" medical care system, and without controlling government medical expenditures there seems little hope of reducing the overall national deficit.

Section 1554 of the ACA states that the Secretary of Health and Human services shall not promote any regulations which limits peoples' ability to get health care or limits doctors' ability to communicate with patients. I hope this remains true, but it remains difficult to see how the country can save money on health care without limiting and rationing such care.

Nevertheless the Congressional Budget Office predicts that with full implementation the ACA will eventually reduce the budget deficit, extend Medicare solvency and increase the Social Security Trust Fund. Are these claims realistic or are they wishful thinking? Only time will tell.