After months and months of acrimonious and partisan debate, personal insults, warnings that civilization as we know it would end and outright lies and more lies about what changes to the American health care system would mean to Americans, the Patient Protection and Affordable Care Act was enacted on March 23, 2010. On March 30, 2010, the Health Care and Education Reconciliation Act of 2010 became effective and amended in many respects the provisions of the Patient Protection and Affordable Care Act. Since the titles of those pieces of legislation are quite the mouthful, let’s simply refer to them here on out as the Health Care Reform legislation.
From the outset , two things are clear.
First, the sky hasn’t fallen as a result of the Health Care Reform legislation. It’s a gorgeous, sunny spring day in Toledo, Ohio, the Cleveland Indians are not batting their collective weight and there are no reports that zombies have overrun the Earth. So the natural order of things is still in place.
Not that there aren’t practical and real problems with the new law. In fact, a review of the legislation, which is just shy of one thousand pages long, reveals drafting errors, complexities and a lack of legislative history that might explain in greater detail what Congress’ intent in regard to several significant issues that arise from the legislation. Those of you who are up to the task are free to read the text of the Patient Protection and Affordable Health Care Act and the Health Care and Education Reconciliation Act.
Too put it mildly, the legislation is hardly a model of clarity.
While the unanswered questions concerning how the Health Care Reform legislation is to be interpreted and applied will have to wait until such time as the various governmental agencies implement relevant regulations, it is nevertheless apparent that the legislation does in fact implement far-reaching and meaningful reforms for American families.
In the first instance, the legislation will ultimately prohibit health plans from imposing lifetime dollar limits on benefits available under a plan. Likewise, annual dollar limits that some health plans impose on participants and beneficiaries will be severely restricted. Furthermore, health plans that provide coverage for dependents must offer coverage to to the children of participants until they reach the age of 26, even if they are married, unless they are covered by another employer-sponsored plan. The legislation will also initially prohibit the imposition of pre-existing condition exclusions for covered individuals under the age of 19. By the year 2014, the prohibition against excluding pre-existing conditions will also be extended to adults. Health plans will also be prohibited from rescinding coverage for individuals except for reasons of fraud and misreprestation.
The Health Care Reform legislation will also require group health plans to report to the Department of Health and Human Services how the premiums they receive is spent. Health plans will then be required to pay rebates to those who pay premiums for health care coverage where the insurance companies that provide benefits spend more than 20% of premium revenue on non-claim costs.
These are real, tangible reforms that will provide relatively immediate benefits to American families and put a top to abusive practices that have long been part of the American health insurance industry.
The above summary will eventually be required of all employer-sponsored group health plans. There will be some delay based on whether the plan was in existence on March 23, 2010 and based on whether the plan is maintained pursuant to a collective bargaining agreement. However, the reforms noted in the above summary will eventually become part and parcel of all group health plans.
Where the Health Care Reform legislation is significantly unclear is regarding a number of additional reforms that will in turn depend upon the status of a group health plan as a “grandfathered” plan. Generally, it appears that a “grandfathered” plan is a plan that was in existence on March 23, 2010. If a plan has “grandfathered” status, it will be exempt from certain additional coverage reform provisions of the legislation (“grandfathered” plans are not exempt from the various reforms discussed above). As if that weren’t confusing enough, the legislation is unclear regarding when plans lose “grandfathered” status.
Keeping mind the uncertainties resulting from the “grandfathered” concept, all other group health plans that are not “grandfathered” are subject to additional reforms. These additional reforms will prohibit “non-grandfathered” plans from imposing cost-sharing requirements in excess of certain maximum amounts, require internal and external appeal procedures for denied claims, prohibit cost-sharing arrangements for certain preventative health services and patient protection procedures.
Aside from the above discussion, the legislation will also mandate a number of health care market reforms that will not be effective the year 2014. These will entail the creation of American Health Benefit Exchanges that will serve as regulated marketplaces through which individuals and eligible employers can purchase health insurance from among competing health insurers and plans. If an employee is offered affordable minimum benefits coverage under an employer-sponsored health plan, he or she will be ineligible to obtain coverage through an Exchange. However, the legislation provides for an opt-out of coverage under an employer plan and the opportunity to obtain government subsidies for Exchange coverage in the event the employee meets certain income requirements and the employer plan costs to the employee exceeds certain household income levels.
The Health Care Reform legislation represents an ambitious plan to curb insurance company abuses and provide working men and women and their families with affordable health care. This discussion represents just a small part of what the legislation entails and is hardly an exhaustive examination of all the law entails.
Having said that, it appears that the long-standing goal of perceiving health care as a right, rather than a privilege, may have finally arrived within our lifetime. Something that has been a dream for activists for generations is actually a reality.
Of course, while changes in health care rights have changed dramatically. Other things never change, like the bumbling ways of the Cleveland Indians.