Some simple truths about health care and health insurance in America are essential to understanding why we are where we are: prior to the Patient Protection and Affordable Care Act (ACA) they weren’t accessible, equitable, or adequate for far too many. Unfair practices in the market led to enactment.
If the playing field had been level the law would never have come to pass. The sweeping changes reflect the institutionalized predatory practices that it ameliorates. In an effort to allow the market to adjust and adapt, there were provisions designed to allow consumers to maintain coverage they believed to be adequate. Of course, the problem has always been that you wouldn’t know if coverage was adequate until you had to use it and then it was too late. It wasn’t as though you could shop around after that revelation; who’d take you on when you were laying in an emergency room? But even the “grandfathered” policies are prohibited from practices insurance companies commonly used to defraud consumers and shelter margins:
- Eliminating benefits;
- Increasing the participants’ percentage cost-sharing requirement;
- Increasing a fixed-amount copayment;
- Reductions in employer or employee organization contribution rates;
- Changes in annual benefit limits; and
- Other abuses
The key to low cost health insurance plans is and always has been restricting benefits. Annual and lifetime benefit limits were generally invisible coinsurance features protecting insurance companies, shifting risk to consumers, often guaranteeing certain policy holder bankruptcy. Other techniques included shifting the burden of health care costs to individual participants by eliminating coverage of specific illnesses so that neither the group nor the insurance company had to absorb the costs. Of course that meant the entire group lost that portion of the coverage too. The ACA doesn’t completely prohibit changes in costs and benefits, but establishes general guidelines so that they are not arbitrary. The ACA also precludes any sleight of hand by employers who restructure the business or change plans in a way designed to diminish costs and benefits provided under grandfathered plans.
The ACA does not require every plan to cover everything and everybody. It does require all plans provide minimum essential benefits. It doesn’t require every plan cover every pre-existing condition, only those conditions for which everyone else is covered under the plan. It simply eliminates discrimination within a plan pool.
If these practices had been the exception instead of the rule, if Americans had been provided adequate and fair coverage by the market, there would be no ACA. The only conclusion one can draw about opponents of the policies enacted in the ACA is that they are either blind to reality or they don’t care that fellow Americans are treated inequitably (or both). They are right about one thing: the ACA needs improvement. But most opponents are simply and blatantly wrong about what should be changed. Their bluster should be directed at the insurance, pharmaceutical, and medical services sectors rather than their victims. And despite the polemic fits, the ACA is, in no way shape or form, socialized medicine.
In a market where the consumer is on a level playing field with vendors the list of services called “essential health benefits” in the ACA, would be the common minimum set of benefits an informed consumer would demand.
Benefit categories that comprise essential health benefits:
- Ambulatory patient services;
- Emergency services;
- Maternity and newborn care;
- Mental health and substance use disorder services, including behavioral health treatment;
- Prescription drugs;
- Rehabilitative and habilitative services and devices;
- Laboratory services;
- Preventive and wellness services and chronic disease management; and
- Pediatric services, including oral and vision care.
Those annual and lifetime benefit limits that used to apply to even these may still be imposed on benefits that are not included in the definition of “essential health benefits.”
A savvy consumer would recognize the essential benefits as the floor and look for enhancements to that very basic coverage. But most people were unaware of the common predatory practices and the only way to learn about them was by falling victim. Consumers were left to rely upon the kindness of strangers before the ACA and are not completely shielded from them today.
There is another insurance industry gimmick that was regulated by the ACA. That is rescission: an insurer’s retroactive cancellation of a policy, usually declaring it to be void from its inception. It has been an ace in the hole for companies taking on new clients who, themselves finally having the opportunity to see a physician now that they are insured, discover ailments that have gone undetected. It was another way to guard against vulnerability to pre-existing conditions. Life insurance companies hiding behind underwriters like to use this card from time to time too, but that is another discussion.
As of 2014 health insurance companies are required to accept all applicants for coverage but may charge varying premiums for the same coverage based on an applicant’s age and tobacco use. Policies that offer dependent coverage are now required to extend their dependent coverage to the policyholder’s children through the month they obtain age 26. Plans that do not offer dependent coverage are not required to provide it. Again, these aspects are part and parcel of leveling the playing field.
Opponents of the ACA love to throw around meaningless platitudes like calling medical care in America the best in the world. It might well be for those who can afford and have access to it. But it also might be near the worst in the world if you live and work in places like our very own Southwest Virginia and very many other under and unserved areas of the country. They don’t have to be rural as evinced by the service being provided by Remote Area Medical with the 2015 clinics delivering service to places like the Tarkanian Basketball Academy in Las Vegas and Anaheim Convention Center in Anaheim California. Last year they were held in the urban areas of New York City, Oklahoma City, and Seattle.
Maybe the good news for Virginians who the General Assembly has decided to leave without coverage is that the number of Remote Area Medical clinics held in the state increases by one in 2015 and breaks out of the southwest. The locations and dates planned for Virginia:
- Wise County – Jul 17 – 19
- Lee County – Sep 12 – 13
- Grundy – Oct 3 – 4
- Warsaw – Nov 14 – 15
Just how many Teapublicans roll up their sleeves and join the volunteers at these clinics will be interesting to observe. It seems this is the very spirit and example of what they view as the best medical care in the world.