Navigating through the muck: Trying to interpret the Affordable Care Act AKA ObamaCare Part 1

Navigating through the muck: Trying to interpret the Affordable Care Act AKA ObamaCare Part 1

By Michol Mae

October 21, 2013

I have been considering writing an article on the Affordable Care Act, AKA Obamacare, for some time now but I have simply not had the time to wade through the befuddling resources available.  However, since it is such a major topic with impacts on the large majority, let us begin on the healthcare.gov site (https://www.healthcare.gov/where-can-i-read-the-affordable-care-act/).  This particular page states “The law has 2 parts: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. We provide links to them in PDF and HTML formats below. We also provide a link to an unofficial, consolidated version that is more readable.”  Already I am confused, but I note the 4 items mentioned: Patient Protection, Affordable Care Act, Health Care, and Education Reconciliation Act.  Okay, the Affordable Care act has a certified full-text version at 2.41MB and the Reconciliation Act is a mere 257KB.  I’m tempted to start with the Reconciliation Act because it’s not only smaller, but I have not seen or heard nearly as much on it, but the lengthy nature of the Affordable Care Act means I will have to break it down, and write an article at a time, in sections.

Oh, here is a clarification! “This Act may be cited as the “Patient Protection and Affordable Care Act”. Terrific! Moving on, you can tell a lot about a book from the Table of Contents and it is no different in this case, 130 page table of contents! Ouch!  

There are parts of parts, subparts of parts, subtitles, I have to say I have my work cut out for me, and as a writer and a librarian I don’t mind a good read and analyze, but I am concerned that the majority of the citizens affected by this would not be so keen on reading it, not to mention at 906 pages an entire college course could be taught on it!

Let’s start at the beginning.  It appears that we start with amendments to the Public Health Service Act in regards to Individual and Group Market reforms for Improving coverage.  The topics that appear here are no lifetime or annual limits, prohibition on rescissions, coverage of preventive health services, extension of dependent coverage, development and utilization of uniform explanation of coverage documents and standardized definitions, prohibition of discrimination based on salary, ensuring the quality of care, bringing down the cost of health care coverage, appeals process  For the sake of keeping the articles short we will cover only a few items in each article, it is my hope this will make it easier to digest and research.

We will start with improving coverage, this says that those offering health insurance coverage cannot establish “Lifetime limits on the dollar value of benefits for any participant or beneficiary or unreasonable annual limits on the dollar value of benefits for any participant or beneficiary” However, if a group health plan or health insurance coverage does not provide essential health benefits they can place annual and lifetime limits per beneficiary on those specific covered benefits. (Page 131 of Public Law 111-148)  One question here, who decides what essential health care is?  Okay, two questions, how is essential health care defined?  Perhaps this is answered in the remaining 775 pages.

The prohibition on rescission tells us that those offering group or individual coverage cannot take back the plan or coverage once you are enrolled unless of course you are fraudulent or intentionally misrepresent yourself, “such plan or coverage may not be cancelled without prior notice to the enrollee.” Be sure to read the terms of the plan and coverage to be safe!

Coverage of preventive health services is a bit more meaty.  It looks like those providing group or individual health insurance coverage  will have to at least provide coverage for ‘‘(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;”  What does that mean, what is A or B, evidence based items?  Wait, I found a resource (http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm).  So it looks like it’s mandatory to include coverage of the following;

• ·         Abdominal aortic aneurysm screening: men
• ·         Alcohol misuses: screening and counseling
• ·         Anemic screening: pregnant women
• ·         Aspirin to prevent cardiovascular disease: men & women
• ·         Bacteriuri screening: pregnant women
• ·         Blood pressure screening in adults
• ·         BRCA screening, counseling about
• ·         Breast cancer preventative medication and screening
• ·         Cervical cancer screening
• ·         Chlamydial infection screening” woman 24 years and younger
• ·         Cholesterol abnormalities  screening men and women ages vary
• ·         Colorectal cancer screening
• ·         Dental caries prevention: preschool children
• ·         Depression screening: all ages
• ·         Diabetes screening
• ·         Falls prevention in older adults: exercise or physical therapy
• ·         Falls prevention in older adults: vitamin D
• ·         Folic acid supplementation
• ·         Gonorrhea prophylactic medication: newborns
• ·         Gonorrhea screening: women
• ·         Healthy diet counseling
• ·         Earing loss screening: newborns
• ·         Hemoglobinopathies screening: newborns
• ·         Hepatitis B screening: pregnant women
• ·         Hepatitis C virus infection screening: adults
• ·         HIV screening: non-pregnant all
• ·         Hypothyroidism screening: newborns
• ·         Intimate partner violence screening: women of childbearing age
• ·         Iron supplementation in children
• ·         Obesity screening and counseling: all
• ·         Osteoporosis screening: women
• ·         Phenylketonuria screening: newborns
• ·         Rh incompatibility screening: first pregnancy visit: fist visit and 24-28 weeks gestation
• ·         Sexually transmitted infections counseling
• ·         Skin cancer behavioral counseling
• ·         Tobacco use Counseling and interventions: all
• ·         Syphilis screening: all
• ·         Visual acuity screening in children

It also looks like immunizations such as Anthrax, BCG, DTaP, Hepatitis A, Hepatitis B, hib, Hib and DTP, HPV, Influenza, Japanese encephalitis, measles, Mumps and Rubella, MMRV, Meningococcal, Pneumococcal, Polio, Rabies, Rotavirus, Smallpox, Tdap/Td, Typhoid, Varicella(Chickenpox), Yellow Fever, Zoster(Shingles) (http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html) must be covered.  Women are covered for additional preventive care and screening mentioned in the list above.  Breast cancer screening, mammography, and prevention is mandatory based on the most current recommendations of the United States Preventative Service task Force.  Anything not mentioned above is not required and there are not limitations for insurance issuers on these additions services.  There is a mention that the Secretary can develop guidelines to permit those that offer health insurance a plan to utilize value based insurance designs, but in this I am not clear on what that means.

The extension of dependent coverage states that those providing health insurance to dependent children will continue to make coverage available for an adult child who is not married until the child turns 26 years of age.  Regulations to not appear to be set at this time, instead it states that the secretary will make known regulation to define the dependents that the coverage should be made available, and the definition of the dependent in the IRS will remain as it was for tax treatment purposes.

 Well folks we made it to page 132 of Public Law 111-148 and I think that is quite enough to digest at the moment.  Check back each week for more, or subscribe to my RSS feed.