What would healthcare consumers have to give up if Republicans succeed in undermining the Patient Protection and Affordable Care Act [PPACA], or if the courts invalidate it? A lot. And much of what we’d have to give up just kicked in on January 1, 2011, with more to come later this year. Once consumers figure out that these goodies are in there, Republicans–and conservative judicial activists–may find themselves on the short end of public opinion.
I acknowledge that healthcare reform, as passed, is far from perfect. I would have preferred Medicare for everyone, and I still yearn for it. But, though they fall somewhat short of nirvana, some of the new rules represent giant leaps forward in fairness and in the effort to make the words “health care” in “health care insurance” live up to their root meanings.
Exhibit A: More dollars for claims
Exhibit A is a structural/conceptual as well as financial change. As of January 1, 2011, the new law generally requires that at least 85 percent of all premium dollars [in large-employer plans] are spent primarily on health care and that at least 80 percent of premiums [for individuals and small groups] are spent on paying claims and improving quality.
If insurance companies don’t meet these goals because their administrative costs or profits are too high, they’ll have to provide rebates to their customers.
This is a significant change for the better. In health-insurance-speak, the relationship between premiums collected and claims paid is known as the “medical-loss ratio.” So, when insurance companies do what they promise to do—cover their customers’ legitimate healthcare costs—it’s seen as a negative on the books. Consumers are justified in finding that term offensive. Worse yet, until January 1, insurance companies were keeping much as 30 to 50 percent of every premium dollar for administrative costs and profit. Consumers have had good reason to be angry with health insurers, whose profits have skyrocketed while payouts for claims have shrunk. The law does not say that healthcare insurers can’t take a profit. It just helps to curb the exorbitant profits amassed by insurers at the expense of the health of the customers they claim to be protecting.
Repeal of health care reform—or a sweeping gut-reno designed by the healthcare lobby—would probably eliminate the premium-spending requirements—a step backwards for healthcare consumers.
Exhibit B: Preventive care
This one’s for older patients. It’s long overdue. And they [we] aren’t going to be okay with turning it back in now that it’s in effect. Under healthcare reform, seniors on Medicare get free preventive services, such as annual wellness visits and personalized prevention plans—with no co-pay or co-insurance.
The law also calls for health-insurance coverage of preventive services for men and women over 50 years old.
Services for 50+ men include screening test for:
abdominal aortic aneurysm, colorectal cancer, depression, diabetes, high blood pressure, high cholesterol, HIV, obesity and sexually transmitted infections.
Women over 50 get screening tests for:
breast cancer, cervical cancer, colorectal cancer, depression, diabetes, high blood pressure, high cholesterol, HIV, obesity, osteoporosis, and sexually transmitted infections.
Exhibit C: Shrinking the doughnut hole
While younger readers may not think “Exhibit C” is a biggie, your Medicare-eligible relatives could be really ticked off if this one gets deep-sixed.
For those who are a generation or two removed from Medicare eligibility—a brief explanation. [If you already know this stuff, skip this paragraph. I’m eligible in less than year, and I still have to review it every time I think about it.] Medicare has several “parts:” Part A covers hospital care and related services. Part B covers non-hospital expenses. Part C is Medicare Advantage. And Part D is the prescription-drug “benefit” passed during the George W. Bush administration. Touted as a way for senior citizens to save money on prescription drugs, it was essentially a huge gift to pharmaceutical companies. Their response, in many cases, was to jack up prices on the most popular drugs, offsetting the “discounts” seniors were getting via Medicare Part D. [Under the terms of the law, Medicare—with its potentially huge bargaining power—was barred from negotiating better prices for its beneficiaries–an astonishingly great deal for big pharma.]
Under Part D, Medicare recipients get coverage for prescription drugs until their expenses reach $2,700 in a one-year period. Coverage picks up again $6,154. In between is the infamous “doughnut hole.”
As of January 1, 2011, under the new healthcare reform law, seniors who fall into the doughnut hole will receive a 50 percent discount when buying Medicare Part D covered brand-name prescription drugs. Over the next 10 years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020.
These changes, which seem likely to be perceived as positive by most people, are among the things that Republicans want to take back through repeal or court rulings. They might want to rethink that strategy. Once people get these benefits, they may react to the notion of giving them back the way Charlton Heston did when he told the National Rifle Association how he’d respond to the idea of surrendering his guns. Look it up, Mr. Boehner.