Key elements of the Patient Protection and Affordable Care Act (ACA) will roll out to all citizens of the United States on January 1, 2013. This phase of the ACA ensures that every citizen in the United States will be able to qualify for health insurance. As coverage expands to millions of people, it will bring many new patients into our world as more than 20 million uninsured are estimated to gain new coverage and access to care they did not have. I am excited for the many people who will now be able to enjoy what we have had in Massachusetts for the last 7 years. In our state, we may not feel dramatic changes because we have been living them since one historic day in Boston's Faneuil Hall. On April 12, 2006, a large banner read "Making History in Health Care" as Governor Romney signed the first universal health care law in the history of the United States.1 Since that day, my personal experience has been surprisingly positive as I, too, feared change and was comfortable in my old reality.
PERSONAL EXPERIENCE FROM THE MASSACHUSETTS COMMONWEALTH CONNECTOR
My family selects our coverage through the Massachusetts Commonwealth Connector. Through the Connector, we were able to "build" a plan that was similar to our employee-based plan, a family plan provided by Harvard Pilgrim as a Preferred Provider Organization Plan. A Preferred Provider Organization Plan allows you to see any doctor of your choice, allowing you more control. This aspect was important to us. We have the same access to Harvard Pilgrim as we did under the employee plan, and we have always been able to have questions or concerns answered by phone, e-mail, or on the Web site. The transition was seamless. Our physicians, locations for care, and access to services stayed the same. The most noticeable changes were seen as the early stages of the ACA provided relief from copays for preventive care and continued coverage of our children as they graduated from college.
So far, the health care reform law has allowed more than 3 million people younger than 26 years to stay on their parents' insurance policy. Two of them are my children! This feature allowed them to stay on our plan through college and the transition into adulthood. Recently, an added benefit was offered to my son who found his "dream job" [horizontal ellipsis]without benefits. Once again, we went to the Connector. There he found a Harvard Pilgrim plan offering coverage under a Young Adult Professional program to bridge the time between 26 and 27 years of age. The monthly premium was only slightly higher than his portion of his employer-based program (the stable "job for life" he quit to pursue the dream). This will change in 2014 when he must select a new plan. However, he may become eligible for a tax credit, to apply to his monthly premium, or to lower his federal tax bill. This is wonderful news for young adults working in startups or pursuing a dream.
My 26-year-old daughter is preparing to move off our family plan soon. She will "buy down" her insurance premium because her employer treats good health behaviors as currency. She will appreciate lower premiums and cost saving for healthy behaviors such as not smoking, annual checkups with her primary care provider, and having yearly biometric test such as fasting blood sugars, lipid profile, and other basic screening test.
A NEW MODEL OF HEALTH CARE EMERGES
Dr Atul Gawande says it well, a new norm is coming into being: if you're a freelancer, or between jobs, or want to start your own business but have a family member with a serious health issue, or if you become injured or ill, you are entitled to basic protection. In addition, the 17 million children with preexisting medical conditions cannot be excluded from insurance eligibility or forced to pay inflated rates.2
Unfortunately, the political debates surrounding this issue obscures many of the facts and potential benefits. Now, more than ever, it is important for nurses and all health care providers to be critically informed about how health care is accessed, paid for, and delivered to our patients. For some patients, we will be the point of contact for this information. Knowing the history of the law is a good place to begin. It is so much more than just a political exercise.
The 2006 Massachusetts law, signed by then Governor Mitt Romney on April 12, provided a blueprint for the 2010 ACA.3 The national ACA was passed by Congress and then signed into law by President Barack Obama on March 23, 2010. On June 28, 2012, the Supreme Court rendered a final decision to uphold the health care law.4 Hmmm[horizontal ellipsis] just writing that sentence makes it sound political!
Yet, as heath care providers, we must stay every mindful that access to health care is a social process, not just a political one. Every health reform system in advanced nations has gone through similar process[horizontal ellipsis] it is the nature of the socio-political process. It seems that every law or policy from the first discussions through legislation to implementation is painful. The history of political discourse about health care reform in our country is long and complicated. However, compromise has brought us to a place that makes sense to me. Making sure that every person has health care coverage they can afford and making sure sick people are getting care are good things. An added bonus includes incentives to help people prevent illness and become active in their own care!
The system is complex and creates fear for many who are inexperienced in insurance matters. Even the language of coverage is confusing to patients and health care providers as well. The full law is readily available to everyone, with plain language interpretations that ensure that all patients can have full access to the key points and many complex sections of the law. At http://www.hhs.gov/healthcare/rights/law/index.html, anyone can read the 10 Titles of the ACA, with amendments to the law called for by the reconciliation process.4 At sites such as this, individuals can learn about health care exchanges and find out if they qualify, then help them select a plan. The fundamental purpose of a health insurance exchange is to provide a structured marketplace for the sale and purchase of health insurance. The exchanges and marketplace format are determined by elements within the ACA that require plans to explain coinsurance, copays, and other shared expenses. Exchanges have additional powers, such as limiting age-based variations in premiums. They also serve to cap the number of plan offered, while requiring that each plan have significant differences. These protections help consumers compare price and service without being confused and overwhelmed.5
WHERE WE ARE NOW
Marketplaces opened for business in October 1, 2013. This allows people who do not have access to adequate and affordable insurance through their employment, spouse, educational institution, or another government program to search for a plan that will fit them. Marketplaces are found at healthcare.gov. Although a new way of seeking coverage, it resembles nothing more sinister than an eBay for insurance.1
Consumers will be able to shop for plans that meet their individual needs. Coverage may be different for some members within a family, or individuals may become eligible through different channels as family composition changes and income varies. The task of the exchanges will be to carry out 4 basic functions for the consumer: (1) determine eligibility and enrollment, (2) consumer assistance and outreach, (3) plan management, and (4) financial management.5
Because it is a marketplace, prices keep falling lower than the Congressional Budget Office predicted, by more than 16% on average. Federal subsidies may trim costs even further, and more people living near the poverty level will qualify for free Medicaid coverage.1
All consumers must become educated about benefits for which they are and are not eligible, and they must understand the basic language of insurance such as deductibles, coinsurance, and copayments. Much of this is similar to home and car insurance language. Out-of-pocket cost will be calculated based on an individual's annual income. A person's total assets are not included, except for interest and dividends as part of regular income. This will help determine how to distribute the burdens of health care cost.6 To make this work, everyone must share the cost before everyone can appreciate the saving. Those who can afford insurance but refuse to buy it will be required to pay a penalty.
OPPORTUNITIES AND CHALLENGES AHEAD
In 2016, exchanges will have to offer insurance to business with 51 to 100 employees. Although they have that option now, it may not be exercised in 2014. In 2017, the ACA authorizes the exchange to consider allowing large employers to contract with them to provide coverage. Many feel the exchange will be an instrument of enormous potential and power.5
There are many who hope the system will collapse and many who will work hard to see it become better. There are too many good things built into the law, and the scope of exchanges coverage will grow. My family has benefited from many components of the law, at a state and national level. We no longer fear that insurance will be canceled if we are diagnosed with a new illness or worry how we will pay for care when lifetime caps run out. We are free to pursue new endeavors, free from a job or hours we were once locked into to keep our "benefits." This year, I will enjoy the fact that my premiums cannot increase because of age[horizontal ellipsis] I will celebrate my birthday without "giving" to my insurance company! And I love the fact that my children are getting to know their primary care doctors and becoming aware of their own laboratory values and are encouraged to make good health choices.
Other things I have come to appreciate include the cleanliness of our hospitals and the focus on quality and safety that I see in my work. Beginning with hand hygiene, and extending all the way to accessing personal medical records from the home computer and mobile devices, it's all good[horizontal ellipsis] and certainly better.
I like Accountable Care, and I like working in an Accountable Care institution.
Enough people, states, and health care interests are committed to making this work; just as our Massachusetts law has for the past 7 years. As nurses, we can utilize our positions as trusted caregivers to inform, educate, and assist patients and families. Become informed, learn the facts about what the law is and is not, and make your decisions based on one of the basic social issues of our time, affordable and accountable health care.
I am hopeful for health care.
Kathleen Ahern Gould, PhD, RN
Adjunct Faculty
William F. Connell School of Nursing
Boston College
Chestnut Hill, Massachusetts
References