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NAVIGATION
PNHP RESOURCES

Questions and Answers about benefits under the Patient Protection and Affordable Care Act (PPACA)

June 23, 2010

Claudia Detwiler M.S.W., M.P.H.
Coordinator of Outreach, Western PA Coalition for Single-Payer Healthcare

1. Question: I have a re-existing condition. When can I get an insurance policy?

2. Question: Is it true that when the high risk pool is discontinued insurance plans cannot discriminate based on pre-existing conditions?

3. Question: I heard that an insurer can still refuse my application based on my health status or my claims experience or medical history. How can this be if they have to accept anyone with a pre-existing condition?

4. Question: Is it true that there will no longer be lifetime limits?

5. Question: I heard that insurance companies can’t cancel policies anymore (recission). Is this true?

6. Question: I understand that I will now be able to receive preventive services, like immunizations or cancer screenings, or well baby care without having to pay a co-pay.

7. Question: If all plans can no longer discriminate based on pre-existing conditions, is it also true that all insurance companies can no longer increase premiums based on pre-existing conditions?

8. Question: Is it true that this new law allows the government to control my health care?

9. Question: If I can’t find a plan that I can afford, can I get subsidy for a plan?

10. Question: Will cost sharing for all plans be limited to the upwardly adjusted HSA (Health Savings Account) maximum, which in 2010 is $5,950 for individuals and $11,900?

11. Question: If I don’t qualify for any subsidy, but qualify for the Exchange, what is the least expensive plan I can get?

12. Question: If my income is between 133% and 400% of the FPL and I qualify for participation in the Exchange, what amount of subsidy can I get?

13. Question: Is it true that I will need to pay over $2085 in penalties even if I can’t find insurance that I can afford?

14. Question: Is it true that no one can force me to give up my employer insurance?

15. Question: Why does reform have to add so much to the bureaucracy? This is what is bad about government in health care.

16. Question: Will every state now have to provide Medicaid to everyone up to 133% of the FPL?

17. Question: How will this be paid for and how will it reduce costs?

18. Question: Since the medical products manufacturers, pharmaceutical and insurance industries are going to be assessed fees, what’s to stop them from passing the costs on to consumers?

19. Question: I heard that my Medicare will be cut under this plan. Is that true?

20. Question: Is it true that Illegal immigrants will now get healthcare and I will pay for it?

21. Challenge: You single payer people don’t like anything. I challenge you to list something good about this plan.


Introduction:

This brief summary is intended to be a tool for single payer advocates to use when discussing the new law in conjunction with the single payer option. In using this, it is important to explain that criticism about the new law is not the same as  antipathy towards government involvement in health care.  Critical analysis of the PPACA is grounded in our vision of what government involvement in health care access looks like when it is truly for the common good.

The summary includes positive aspects to the law, as well as its more dubious aspects.  The idea is to build  bridges to audiences which have heard about the “good stuff”, while helping them to understand that the benefits are considerably fewer, and far less secure, than what is being presented-and many, many, times less than what a single payer plan would bring.

These summary is not intended to present the PPACA is a “stepping stone” to single payer. The intent is to encourage people to think critically about what they will (and won’t) receive and what they could yet have with single payer.

This paper focuses on aspects to the law of interest to a general audience.

The web sites below provide additional summary information for people wanting to learn about the dozens of sections of the law not discussed here.

Kaiser Foundation Summary of bill-Focus on Health Reform
http://www.kff.org/healthreform/upload/housesenatebill_final.pdf
 
British Medical Journal, March 30, 2010
Obama's reform: no cure for what ails us: By David U. Himmelstein and Steffie Woolhandler
http://www.bmj.com/cgi/content/full/bmj.c1778?ijkey=qLFfFBwLmfvN8vo&keytype=ref

Congressional Research Service
http://bingaman.senate.gov/policy/crs_privhins.pdf


Note: Before beginning a discussion, explain to your audience/acquaintances about “grandfathered” plans.  This is critical to understanding the actual benefits of the PPACA.

A Grandfathered Plan is any group health plan or health insurance coverage in which an individual was enrolled on the date of enactment (March 23rd, 2010). Policies that are renewed, or which add family members or new employees are included as “grandfathered”. This means that all current employer plans are exempt from many of the benefits of the new law. “Interim final regulations” have been issued to establish conditions which will cause a plan to lose its “grandfathered” status but it is not clear how many plans will be affected by this. Also, insurance companies are setting aside billions to lobby for final regulations to make grandfathered status  as generous to insurance companies as possible. Where a benefit does include grandfathered plans, it is also important to note whether the benefit includes all grandfathered plans or only group grandfathered plans but not individual plans.

In 2014, when insurers will be required to maintain a single risk pool for all of their individual market policies in a state and a single risk pool for all of their small group market policies in a state, grandfathered plans will not be required to be included in those single risk pools. This will have the effect of eliminating the healthier (employed) people from the risk pool, thereby increasing the cost of insurance available through the Exchange.

Please see the last section of this paper for a summary of PPACA exemptions regarding grandfathered plans.


1. Question: I have a re-existing condition. When can I get an insurance policy?

Response: People with pre-existing conditions are to have access to insurance through a high risk pool. This is to be available 90 days from passage-June 21. Access to the pool will continue until 2014. To be eligible, you must be a citizen of the U.S. who has a pre-existing condition and has not been covered under creditable coverage during the 6‐month period prior to the date on which you are applying for the pool.

Beginning six months after passage, (September 23), children (those under age of 19) with pre-existing conditions cannot be denied coverage

Also six months after passage, you can add dependant coverage for children through age 26 for all plans (except for grandfathered plans where the dependent is eligible for employer‐based insurance)

Cautions worth knowing:

(a) Based on the amount of money allocated for this pool, only a small percentage of those expected to need this support will be covered.

(b) The high risk pool is permitted to rate premiums by age on a 4:1 factor.

(c) A person in the high risk pool can be required to cover as much as 35% of any treatment out-of-pocket. Insurers are only required to cover 65% of the cost.

(d) Maximum cost-sharing will be limited to the current law HSA (Health Savings Account) out-of-pocket limit ($5,950/individual and $11,900/family in 2010) but this does not include premiums.


2. Question: Is it true that when the high risk pool is discontinued insurance plans cannot discriminate based on pre-existing conditions?

Response: Yes…but

As of 2014, all plans, including group (but not individual) grandfathered plans, will no longer be permitted to discriminate based on pre-existing conditions.

Cautions worth knowing:

(a) A plan can still deny a treatment approved by your doctor, including treatment for a pre-existing condition.

For example, plans in the Exchange-and new individual and small group plans outside the exchange- must include an essential benefits package that includes preventive and wellness services, chronic disease management, maternity and newborn care, mental health and substance use disorder services, and pediatric services, among other things. This is good but it is not the same as a standard list of treatments for a particular condition. Your plan could deny a claim for an expensive treatment while not actually denying coverage for a “pre-existing condition”.

(a) Also, grandfathered group plans (current employer plans), while prohibited from denying applications for pre-existing conditions as of 2014, are not required to offer even the essential benefits package. This gives them even more flexibility in denying treatment while still meeting the requirement of not discriminating based on pre-existing conditions.

(b) An industry might also attempt to limit their financial exposure-while still being within the law-by offering a lot of low premium, high deductible, high co-pay policies. People with modest incomes will buy them in spite of the limited benefits but not be able to afford the deductible and/or co-pays- in which case, the insurance company receives revenue from premiums without having to pay out claims.

(c) Insurance companies will try to reinterpret anything and everything:  Only a few days after the bill was passed, insurers denied that they were obligated to issue coverage to children with pre-existing conditions. They argued that they were only prohibited from denying care to a child with a pre-existing condition who was already covered. Under pressure, they reversed their decision, but this indicates that a for-profit industry will continue to undermine requirements anyway they can.


3. Question: I heard that an insurer can still refuse my application based on my health status or my claims experience or medical history. How can this be if they have to accept anyone with a pre-existing condition?

Response: Good Question! Grandfathered plans (current plans) are not included in prohibitions on eligibility rules based on health status related factors. These are different from pre-existing conditions. Health status factors include: health status, medical condition (mental or physical illness), claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), disability, or any other health status‐related factor as determined by the HHS Secretary.

Guaranteed Issue and Renewability are related requirements for which grandfathered (current) plans are also exempted. Guaranteed Issue and Renewability mean that a plan in a state must accept every employer and individual that applies for coverage in the State.  New Individual plans or small group plans must comply as of 2014, but current plans do not need to comply.

These exceptions for grandfathered plans means that they cannot deny you a policy based on a pre-existing condition but they can deny a policy for a number of other factors pertaining to your medical condition.


4. Question: Is it true that there will no longer be lifetime limits?

Response: Lifetime limits will no longer be permissible as of six months (Sept 23) for new individual and group plans and for grandfathered group plans (but not grandfathered individual plans), however annual limits are only “restricted” at the 6 month period-not eliminated until 2014-and then only for all new plans and grandfathered group plans-but not grandfathered individual plans.

Cautions worth knowing:

(a)  The prohibitions of lifetime and, eventually, annual limits are limited to "essential health benefits"-a category not yet fully defined by the DHHS.  Also, grandfathered individual and group plans do not have to include “essential health benefits”.

(b) Presumably, if a person had reached their annual limit for treatment in a given year they could be denied treatment until the beginning of the next plan year.

(c) Many people, whether in the Exchange or not, will find the premiums, deductibles, co-pays and other out-of-pocket expenses sufficiently burdensome that they will declare bankruptcy or simply stop getting care before ever reaching their lifetime caps.


5. Question: I heard that insurance companies can’t cancel policies anymore (recission). Is this true?

Response: Yes…and no.

As of the six month period (Sept 23rd) all plans (including grandfathered plans) will no longer be allowed to cancel policies arbitrarily.

Cautions worth knowing:

(a) They are still allowed to cancel policies based on findings of fraud and intentional misrepresentation, as defined by them. This is the most common reason now for cancelling policies. In the past, companies have used this freedom expansively to limit payments and cancel policies.

(b) Recission (cancelling policies to avoid expenses) has always been illegal but this was not enforced by state regulators. Going forward, already financially overburdened states will be required to take on the cost of the Exchanges, expanded Medicaid and additional regulation, which could mean that oversight for abuses such as recission will be spread very thin.


6. Question: I understand that I will now be able to receive preventive services, like immunizations or cancer screenings, or well baby care without having to pay a co-pay.

Response: Yes…and no. This only applies to new individual and group plans. Existing grandfathered plans (current employer) do not have to offer this.


7. Question: If all plans can no longer discriminate based on pre-existing conditions, is it also true that all insurance companies can no longer increase premiums based on pre-existing conditions?

Response: No

Only new individual and small group plans (less than 100 employees) are prohibited from increasing premiums based on pre-existing conditions. Large group plans and all grandfathered plans are not prohibited from raising premiums based on pre-existing conditions.

Cautions worth Knowing:

(a). Even the individual and small group plans are permitted to vary premiums based on age (3:1), geography, family size, and tobacco use. These are all indirect ways to regulate based on pre-existing conditions.

(b)  Large group and grandfathered plans are also permitted to increase premiums based on gender, as well as pre-existing conditions-and any other factors they choose. Many summaries of the new law mistakenly pronounce gender rating as prohibited but it is only prohibited in the individual and small group markets.This allowance for gender rating will have an especially harmful impact in workplaces where women predominate.

(c )  Employers can offer increased incentives to employees for participation in a wellness program or for meeting certain health status targets beginning in 2014 under the Patient Protection and Affordable Care Act. The law will permit rewards or penalties such as premium discounts of up to 30 percent of the cost of coverage. While this might appear to be a worthwhile goal, it can be a back door way to permit increased premiums for people who, for whatever reason, cannot achieve that goal, coming close to a form of premium discrimination for pre-existing conditions.

(d) Insurance commissioners in 27 states already have the power to regulate premium hikes, but have been ineffective in controlling them.

(e) Stock prices for virtually all the leading private insurers remain high and have been trending upward. Investors are also bullish on the promising prospects for the drug companies and for-profit hospitals, suggesting that premium increases are a real possibility.


8. Question:  Is it true that this new law allows the government to control my health care?

Response: Your health care will continue to be provided by private medical providers, just as it is now. What the law does is limit (not not eliminate) the ways in which private insurance companies get between you and your health care. The law puts some restrictions on insurance company practices that have limited or denied access to coverage.

Cautions worth knowing: As described above, these restrictions are subject to much manipulation and many do not apply to grandfathered (current) plans.  By contrast, in a single payer Medicare for All plan, government involvement would actually be less because the goal of government, unlike private industry, is not to make a profit from your need for health care. The government is the greatest protector of your doctor patient relationship. In a single payer plan developed by public and private stakeholders, the shared goal is to maintain and restore people’s health. In a private insurance, fragmented model, the goal is to manage costs by denying care and shifting sicker patients who limit profits to public plans-a much more intrusive approach.


9. Question: If I can’t find a plan that I can afford, can I get subsidy for a plan?

Response: Not necessarily:

-If the lowest cost plan available is greater than 8% of your income, that plan would be considered “unaffordable” and you would not have to pay a penalty for not purchasing a plan, , but that doesn’t guarantee you a subsidized plan. Subsidies are referred to as “premium credits and cost sharing”. Your income level must be between 133% and 400% of the FPL to qualify for subsidy.

Even if you choose to purchase a policy in the Exchange (state created and regulated markets for purchasing plans) and the policy premium is greater than 8% of your income, you still do not qualify for a subsidy unless you are within the FPL guidelines.

-Also, the level of mandated minimal coverage for policies offered in the Exchange still leaves individuals and families with a sizable financial exposure. The two lowest cost levels in the Exchange provide coverage for only 60% or 70% of “benefit costs”. Exposure for the remaining 30% or 40% includes deductibles and co-pays. It does not include the several thousand dollar premium for the policy itself, a cost in addition to the 30 or 40% exposure.  Independent researchers predict that insurance premiums will, at best, be not much lower than they are currently. Out of pocket expenses in the Exchange are capped in 2014. The cap is based on the HSA (Health Savings Account) maximum which will be adjusted upward from the 2010 amounts of $5,950 for individuals and $11,900.
              
-If you are employed and your employer offers a plan, the standard for a plan being “unaffordable” is different. Instead of 8%, it is 9.5% and you can then choose to purchase a plan in the Exchange as an alternative. However, this still does not guarantee you a subsidy. Your income must be less than 400% of the FPL to qualify for a subsidy even if your employer plan is 9.5% of your premium. You also have the option of purchasing a plan in the Exchange if your employer provided plan covers less than 60% of the cost, but the same income limitation applies regarding a subsidy for that plan.

-If your income is below 400% of the FPL and if your employer premium is greater than 8% but less than 9.8% (some sources say 9.5%) of your income, you can choose to purchase a plan in the Exchange and receive a subsidy. In addition, your employer is required to provide a voucher to offset the government subsidy of your plan. The voucher will be for the amount that your employer would have contributed to your premium.


10. Question: Will cost sharing for all plans be limited to the upwardly adjusted HSA (Health Savings Account) maximum, which in 2010 is $5,950 for individuals and $11,900?

Response: No. Grandfathered plans (all current plans) do not have to provide limits on your out-of-pocket expenditures or their premiums and only new plans in the Exchange do.

One provision in the law bars insurers in the Exchange from “unreasonable premium increases” and requires large increases to be submitted to federal and state officials, but “unreasonable” is undefined and the insurance industry is setting aside billions of dollars to lobby for the most relaxed definitions possible.


11. Question: If I don’t qualify for any subsidy, but qualify for the Exchange, what is the least expensive plan I can get?

Response: The least expensive qualifying plan is the Bronze plan, which covers 60% of the benefit costs of the plan with an out-of-pocket limit, based on the current $5,950 for individuals and $11,900 for families in 2010. This is effective in 2014, at which time the limit will be adjusted upward from the 2010 amount.


12. Question: If my income is between 133% and 400% of the FPL and I qualify for participation in the Exchange, what amount of subsidy can I get?

Response: Subsidy will be in the form of “advanceable and refundable” premium credits. This means you will receive a refund even if you have no tax liability and your “credit” is available when you purchase the plan. The credit is calculated on a sliding scale beginning at two percent of income for those at 100 percent FPL and phasing out at 9.5 percent of income at 300-400 percent FPL.

The Treasury Dept will pay the premium credit amount directly to the insurance plan in which you are enrolled. You will then pay to the plan the dollar difference between the premium tax credit amount and the total premium charged for the plan.

The credits will be tied to the second lowest cost “silver plan” in the area and will be set on a sliding scale. The silver plan has an “actuarial value” of 70%, meaning that the plan (not you) pays 70% of benefit costs. You pay 30% plus premium costs.

Premium contributions are limited to the following percentages of income for specified income levels: Provisions related to the premium and cost sharing subsidies are effective January 1, 2014.

Up to 133% FPL: 2% of income

133-150% FPL: 3 – 4% of income

150-200% FPL: 4 – 6.3% of income

200-250% FPL: 6.3 – 8.05% of income

250-300% FPL: 8.05 – 9.5% of income

300-400% FPL: 9.5% of income

Cost-sharing subsidies for deductibles, co-pays and co-insurance are also provided to eligible individuals and families, but only up to 250% of the FPL. These subsidies reduce the 30% cost-sharing exposure. Above 30%, the cost sharing exposure remains at the 70%/30% level.

Premiums are not included in the cost-sharing limitations but are subsidized separately as described above.

Out of pocket maximums ($5,950 for individuals and $11,900 for families in 2010) are reduced to one-third for those with income between 100-200 percent FPL, one-half for those with incomes between 200-300 percent FPL, and two-thirds for those with income between 300-400 percent FPL. Credits are available for eligible citizens and legally-residing aliens. 


13. Question: Is it true that I will need to pay over $2085 in penalties even if I can’t find insurance that I can afford?
 
Response: No.  That amount is the maximum anybody would be required to pay; it is based on income and it is not in effect until 2016.  Also, it is waived if the only coverage available is greater than 8% of your income.

Here is a summary of the law: “Those without coverage pay a tax penalty of the greater of $695 per year up to a maximum of three times that amount ($2,085) per family or 2.5% of household income. The penalty will be phased in according to the following schedule: $95 in 2014, $325 in 2015, and $695 in 2016 for the flat fee or 1.0% of taxable income in 2014, 2.0% of taxable income in 2015, and 2.5% of taxable income in 2016. Beginning after 2016, the penalty will be increased annually by the cost-of-living  adjustment.”  The flat fee is applied to all members of the family, but at the ½ rate for children under 19. That is how a family could have a fee of $2085 in 2014 and not $695.

So if your taxable income in 2016 was $150,000, 2.5% of that would be $3,750. However, you would only be required to pay $2085, not $3750-and not until 2016. If you income was $50,000, (and again, this is only by 2016) you would be required to pay $1,250-the greater of 2.5% of income or the minimum of $695.  If you are very low income, you can be exempted from any payment if the least expensive plan available is 8% or greater of your income or if your income is below the tax filing threshold (in 2009 the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples).

Other exemptions are for those without coverage for less than three months, undocumented immigrants, incarcerated individuals, and other hardship wavers.


14. Question: Is it true that no one can force me to give up my employer insurance?

Response: Yes

Cautions worth knowing:

(a).  Another way to look at this, though, is that people with employer-based coverage will be locked into their plans' "preferred providers' networks."

(b). Also, you can keep your plan until you can’t afford the (highly likely) ever-increasing prices or your employer drops the plans. Remember that grandfathered plans (current employer plans) are exempt from the premium limitations of plans in the Exchange.

(c). The penalties for employers who do not provide coverage are too small to discourage them from canceling or cutting back on increasingly costly employee benefits and several large corporations are considering just this.


15. Question: Why does reform have to add so much to the bureaucracy? This is what is bad about government in health care.

Response:  The huge new bureaucracy is the result of trying to provide increased access to care while keeping in place the entire “middleman” private insurance industry. A private insurance industry is not in the business of providing care or expediting access to care. Its reason for existence is to make a profit off of your need for care by standing between you and your care.

The bureaucracy, then, is the result of needing to build a complex, expensive structure to regulate a private, largely for-profit industry which must, as a for-profit industry- find ways to not comply with regulation. It is a very, very expensive cat and mouse game that drives up costs while maintaining a barrier between you and your medical care.

A single payer program would eliminate the huge financial burden to consumers, employers and the country of accessing care through a private industry that takes its costs and profits off the top and increases the costs for every provider.


16. Question: Will every state now have to provide Medicaid to everyone up to 133% of the FPL?

Response: Eligibility is extended to all individuals underage 65 (children, pregnant women, parents, and adults without dependent children) with incomes up to 133% FPL, but the fact that eligibility has been extended does not mean that states must provide the benefit to that extent. The states are allowed to demonstrate hardship to reach this goal. States are financially overloaded already, and are now facing additional pressures for financing the new exchanges and greater insurance oversight. Medicaid is financed with matching state and federal funds. While the federal government may have the money to pay for expanded eligibility, most states don't. States can also extend the eligibility but reduce payments to physicians, limiting access to care for low income people.

Also, public hospitals that treat the uninsured will have their federal funding slashed by $36 billion, adding to state burdens to provide care to lower income people who previously received care here.


17. Question: How will this be paid for and how will it reduce costs?

Response: The plan is reported to be cost neutral, meaning that the increases in public spending (the $447 billion to the insurance industry and the $551 billion for regulations and management of this complex arrangement), will be offset by savings in the system. Paying for this is a combination of cost savings and increased revenue.

The revenue side: Increase the threshold for the itemized deduction for unreimbursed medical expenses from 7.5% of adjusted gross income to 10% of adjusted gross income for regular tax purposes (waive the increase for individuals age 65 and older for tax years 2013 through 2016. (Effective January 1, 2013)

Increase the Medicare Part A (hospital insurance) tax rate on wages by 0.9% (from 1.45% to 2.35%) on earnings over $200,000 for individual taxpayers and $250,000 for married couples filing jointly and

Impose a 3.8% tax on unearned income for higher-income taxpayers (thresholds are not indexed). (Effective January 1, 2013)-plus limitations on HSA s

Increase revenue by the elimination of some forms of tax subsidy of employer plans, such as the double pharmacy benefit where employers get a subsidy for managing a plan that provides access to Medicare Part D for their employees and (used to) be able to not declare the subsidy as income while writing off the subsidy as expenses for the plans to reduce their taxable income.

Cost Savings:

The stated plan is to reduce existing health care costs through increased emphasis on reducing fraud & abuse, administrative simplification (although the law does not specifically address the need for comprehensive uniformity of all data and information requirements), demonstration projects around areas of coordination of care, computerization of medical records, tort reform reducing excess provider/insurance payments.

Cautions worth knowing:

(a) The evidence on the above areas is that they are marginal at best at reducing costs, sometimes just the opposite. For example, tort reform is an emotional issue, but studies show that it is very marginal in its impact on costs of medical care.

Also, countries with a true, publicly financed universal healthcare system like single payer have almost no issue around excessive medical law suits. People don’t sue for lifetime potential medical care costs because they always will have that. Physicians pay a fraction of what our doctors pay for liability insurance.

(b).These presumed efficiencies are dependent on the insurance industry not fighting them. The health care industry spent a record $266.8 million last year making sure nothing got into the bill that would seriously threaten its profits. It will be even better funded going forward to oppose sections most detrimental to insurance company interests.

(c) Savings are also dependent on the insurance industry not raising premiums -which is already happening. The law imposes oversight on “unreasonable” premium increases but does not define “unreasonable”. Insurance companies are organizing to push for a generous definition of “unreasonable” in the rule making process to implement the PPACA. The rationale for mandated purchase of insurance is that insurance companies would not have to increase premiums if plans covered younger, healthier people as well as sicker people. Soon mandated coverage of pre-existing conditions will become the “explanation” for why they have to increase premiums substantially.

(d) The wealthiest Americans will resist increased taxation and the insurance and pharmaceutical industries will resist fees.

(e)  All of these potential savings are extremely minor compared to the elephant in the living    room:  the private, for-profit insurance industry that takes its profits and high costs off the top.

(f). This law does nothing to decrease the 31% of healthcare costs ($400 billion) that we spend pushing paper to figure out who’s going to pay for care. With a single payer system, this reduction for allow us to not only cover ALL people, not leaving out 23 million, but cover us all with expanded services.


18. Question: Since the medical products manufacturers, pharmaceutical and insurance industries are going to be assessed fees, what’s to stop them from passing the costs on to consumers?

Response: There will be a fee oversight process… but

Cautions worth knowing:

(a) Premium oversight in the past has not been very effective. Insurance commissioners in 27 states already have the power to regulate premium hikes, but have been ineffective in controlling health care costs.

(b) The fees will be an incentive for insurance companies to find as many ways as they can to get around the new regulations in order to maintain their profits, in addition to increasing premiums.  Drug makers have raised wholesale prices on brand name drugs by 9 percent this year alone in anticipation of reform. The same thing happened prior to the implementation of Medicare Part D.

(c) Wall Street loves the law. Mutual fund analysts say it is beneficial for health industry stocks, particularly for pharmaceutical and medical equipment companies, because there are no “onerous cost controls.” Health insurance company stocks continue their upward trend, and CEO salaries remain astronomical.

(d) By contrast, with Improved Medicare for All, pharmacy and medical care prices will be set by a national body of stakeholders-including the pharmaceutical industry and medical care providers-and your needs would be covered. A private industry could not unilaterally raise prices to increase profits.


19. Question: I heard that my Medicare will be cut under this plan. Is that true?

Response: There are two changes that have led to this concern.

The first is the gradual reduction in payment to Medicare Advantage plans. This has been intentionally misrepresented to oppose any reform. These are private plans that have been given permission to sell Medicare policies. They have been receiving at least 15% more per enrollee (for some plans the added payment is up to 18%) above what the government spends per enrollee for regular Medicare.  Much of this goes to high management salaries and profit to shareholders for doing the same job that the government is doing for much less. Many plans only provide minimal “preventive” services to justify this added cost- and there is minimal oversight of Medicare Advantage plans to justify these higher payments.

This is public funding which should be re-directed into expanded Medicare for all enrollees.

The second change that has led to concern is the requirement to establish an Independent Payment Advisory Board to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds a target growth rate. The Board is prohibited from submitting proposals that would ration care, increase revenues or change benefits, eligibility or Medicare beneficiary cost sharing (including Parts A and B premiums), or would result in a change in the beneficiary premium percentage or low-income subsidies under Part D

However, much touted “Delivery system reforms” will produce almost no savings according to both the Congressional Budget Office and the chief actuary of the Medicare program. There is reason to be concerned that cuts could be made to Medicare payment rates for those providing services to the beneficiaries and this is a cause of real concern.

There are a number of Medicare changes that should benefit beneficiaries. Here are a few of them.

· Provide a 10% bonus payment to primary care physicians in Medicare from 2011 through 2015. (Effective for five years beginning January 1, 2011)

· Provide Medicare beneficiaries access to a comprehensive health risk assessment and creation of a personalized prevention plan. (Health risk assessment model developed within 18 months following enactment)

· PPACA increases Part D premiums for higher income enrollees; the income thresholds are to be set at the same level and in the same manner as those used to establish Part B premiums. Also, starting in 2011, Part D enrollees will be provided discounts of 50% for brand-name drugs during the coverage gap. In addition, the Reconciliation Act provides a rebate of $250 to enrollees who enter the coverage gap in 2010 and phases out the Part D doughnut hole by gradually reducing the cost sharing during the coverage gap for both brand-name and generic drugs until it equals 25% of the negotiated price of the drug in 2020.

· Medicare Part D coverage gap (phased in beginning in 2011); Between 2014 and 2019, reduce the out-of pocket amount that qualifies an enrollee for catastrophic coverage; Make Part D cost-sharing for full-benefit dual eligible beneficiaries receiving home and community-based care services equal to the cost-sharing for those who receive institutional care (Effective no earlier than January 1, 2012);

· Prohibit Medicare Advantage plans from imposing higher cost-sharing requirements for some Medicare covered benefits than is required under the traditional fee-for-service program. (Effective January 1, 2011)


20. Question: Is it true that Illegal immigrants will now get healthcare and I will pay for it?

Response: No, they will not get care as a result of this act.

Cautions worth knowing: Many people argue that restricting care in this way is not in our self-interest. Our country and our health are better off when people who are here are not sick with potentially contagious diseases.

The bill imposes a 5-year waiting period on permanent, legal residents before they are eligible for medical assistance, and prohibits undocumented workers even to use their own money to purchase health insurance through an exchange. These provisions are also counterproductive in terms of controlling health care costs.


21. Challenge: You single payer people don’t like anything. I challenge you to list something good about this plan.

Response: Here are some of the better aspects to this law:

Increased funding for community health centers is a good thing (although public hospitals that treat the uninsured will have their federal funding slashed by almost $40 billion).

Increasing the eligibility for MA is a good thing.

Simplifying enrollment for MA and CHIP is a good thing

Increasing reimbursement for MA and Medicare in some areas is a good thing.

Requiring Medicare to offer annual physicals with no cost sharing is a good thing.

Limiting contributions to HSAs is a good thing. HSAs shift taxes from wealthier to middle income  people.

Charging people with high incomes more is a good thing

Encouraging more primary care physicians and greater use of physician assistants and nurse practitioners is a good thing.

Reining in some of the abuses of the health insurance industry is a good thing.

Easing and eventually eliminating the donut hole is a good thing

Reducing the excess payment for private Medicare Advantage plans is a good thing.

Allowing young adults to remain on their parents plan

BUT-all of this, and much, much more in terms of expanded care, could happen through an improved Medicare for All plan. The end result would be direct access to health care through a much less complicated plan that covers everybody, automatically, equally, and in a simple but comprehensive plan, based on ability to pay. This would be based on our current Medicare but with expanded benefits, from prevention through long term care. Also, unlike current Medicare, there would be no co-pays or deductibles. And Expanded Medicare for All would cost no more than we now spend instead of increasing health care costs by billions of dollars.

This is not too good to be true. In fact, every other industrialized country, and many countries that struggle more financially, provide this for their people.

Your money and mine would be going to pay for our care and not for (1) the bloated costs of an insurance industry that gets a claim on your money before it goes to the providers, with no value added (2) a complicated and expensive bureaucracy overlay to control that same industry (that adds nothing to health care delivery) (3) the major costs that doctors and hospitals incur as a result of  billing to hundreds of insurance companies, often multiple times for each claim before the claim is finally paid and (4) complicated exchanges and multiple separate funding and qualifying categories to provide care to people with middle and lower incomes and a variety of special needs.

You could simply send your money, based on ability to pay, directly to a government pool that sends it to the providers and eliminates these four huge cost areas. Presently 1/3 of each health care dollar goes to the paperwork and claims shuffling costs of the current approach. With a single payer system, most of these costs would disappear for providers and for administration of the plan. The estimated savings of $400 billion would go directly to providing more services for all of us.

The new law not only keeps this $400 billion of wasted dollars in the system-with no increase in services, it adds another $447 billion over the next ten years to the same private insurance industry which now wastes our money processing and denying claims. This is nothing more than another corporate bailout of a failed system.  It also adds another $551 billion of tax dollars to fund the expensive regulatory mechanism and exchanges, and other changes in the private and public system. All of this additional funding could instead go to funding expanded services to all of us.

Radical?  No. Untried? No

Literally dozens of other counties, with better health outcomes than the US, and costing less individually and nationally than the U.S., provide care for their people based on the following principles:

1. Strong central public process for planning for comprehensive healthcare and for annual review

2. Widely shared cultural belief that all people should take care of one another

3. Shared belief that no one should go bankrupt, or suffer financially, in order to receive medical care

4. Belief that profit should play no role, or a very minimal role, in the design of a healthcare program.

5. Commitment to equal access to quality care regardless of income.

7. Strong protections for doctor patient privilege

8. Comprehensive Care and uniform benefits: prevention through long term care

9. Premiums or contribution to the system is based on ability to pay.

10.The sicker you are, the less you pay. This applies to major illness and multiple illnesses within a family.


Additional Information Regarding “Grandfathering”

Grandfathering of Health Insurance Coverage; Minnesota Dept of Commerce Insurance Gateway. (http://www.state.mn.us/portal/mn/jsp/content.do?id=536896358&contentid=536919681&contenttype=EDITORIAL&programid=null&agency=Insurance)

The legislation does specifically apply a number of provisions to grandfathered plans from which they would otherwise be exempt.  These provisions include:

    * Section 2708 (relating to excessive waiting periods);
    * Provisions of section 2711 relating to lifetime limits (but not those dealing with annual limits);
    * Section 2712 (relating to rescissions); and
    * Section 2714 (relating to extension of dependent coverage) 

Other provisions are applied only to group plans that are grandfathered.  These provisions are:

    * Provisions of section 2711 relating to annual limits;
    * Section 2704 (relating to pre-existing condition exclusions); and
    * Section 2714 (relating to coverage of adult children) only if the adult child is not eligible for their own employer-sponsored coverage.

Grandfathered plans are exempt from all other provisions of subtitles A (immediate reforms) and C (market reforms).  These provisions include the following reforms that go into effect prior to 2014:

    * First-dollar coverage of preventive health benefits (§2713)
    * Utilization of uniform explanation of coverage documents and standardized definitions (§2715)
    * Provision of additional information (§2715A)
    * Prohibition of discrimination based upon salary (§2716)
    * Ensuring the quality of care (§2717)
    * Bringing down the cost of health care coverage (§2718)
    * Internal and external appeals (§2719)
    * Patient protections (§2719A)
    * Health insurance consumer information (§2793)
    * Ensuring that patients get value for their dollars (§2794)

Grandfathered plans are also exempt from the main market reforms that go into effect on January 1, 2014.  These provisions include:

    * Fair health insurance premiums (§2701)
    * Guaranteed availability of coverage (§2702)
    * Guaranteed renewability of coverage (§2703)
    * Prohibition on discrimination based upon health status (§2705)
    * Nondiscrimination in health care (§2706)
    * Comprehensive health insurance coverage (§2707)
    * Coverage for individuals participating in approved clinical trials (§2709)