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Health care reform gets mixed reviews one year later

From the May ACP Internist, copyright © 2011 by the American College of Physicians

By Robert B. Doherty

It’s been a little over one year since the Affordable Care Act was signed into law by President Obama. How is it faring? It depends on whom you ask.

President Obama and his congressional allies argue that many people already are experiencing better benefits and better health. The White House blog, for instance, recently highlighted the benefit to small businesses of tax credits and coverage of preventive services. Republican leaders in Congress call it a job-crushing piece of legislation that should be repealed, and remain determined to cut off its funding. Meanwhile, polls show that the public remains divided down the middle, with opinion being largely unmoved from a year ago.

Putting the politics aside for the moment, though, what has been the impact so far of the Affordable Care Act on access and cost of care?

For most Americans, the changes have been fairly modest, mainly because the biggest expansions of coverage don’t happen until 2014. In 2014, Medicaid will be required to cover all Americans with incomes up to 133% of the federal poverty level, and tax credits will be made available for people with incomes up to 400% of the poverty level to buy coverage from a qualified health plan.

Also in 2014, all insurers will also be prohibited from turning down or charging excessively more to people with pre-existing conditions, qualified health plans will have to offer one of four standard benefits packages, and state health exchanges will allow one-stop shopping for qualified health plans. In the meantime, though, millions of Americans are benefiting from the Affordable Care Act’s changes.

Seniors in the traditional Medicare program have benefited from improved coverage of preventive services and prescription drugs. The Department of Health and Human Services reported that 150,000 seniors—2,800 per day—had received a new covered wellness visit in just the first two months since the benefit went into effect on Jan. 1. Many also are benefiting from coverage of preventive screening tests, like mammograms, that are now offered at no cost to them. Last year, 4 million beneficiaries who fell into the Medicare Part D doughnut hole received a $250 rebate check from the federal government, and this year, about 3 million will benefit from a 50% discount on brand-name drugs.

The White House estimates that up to 72,000 children with pre-existing conditions no longer can be denied health insurance. The ACA also created temporary high-risk insurance pools for adults with pre-existing conditions, as a transitional program until all insurers are required to cover them starting in 2014. But enrollment in the high-risk pools has been far lower than originally expected. Only 12,000 adults have enrolled, far fewer than the 200,000 people that the Congressional Budget Office had estimated.

The federal government estimates that about 1.2 million young adults between the ages of 19 and 26 will now be able to get coverage from their parents’ plans.

A study conducted on behalf of the Small Business Majority, a Democratic-leaning business group, found that more than 4 million small businesses (83.7% of all in the country) will be eligible to receive a tax credit for the purchase of employee health insurance in tax year 2010. It is not yet known, though, how many of them will actually claim the credit.

Critics allege that instead of helping small businesses, the ACA has driven up premium costs, citing double-digit increases in the small group and individual insurance market. However, www.factcheck.org, an independent and non-partisan website, found that “premium rates for many in the individual market are going up ... But state insurance commissioners and health care experts told us the Patient Protection and Affordable Care Act is responsible in most cases for only a small portion of these increases. The main cause of double-digit rate hikes is rising medical costs.”

General internists, family physicians and pediatricians who provide mostly primary care are benefitting from a 10% increase in Medicare payments for their office and other outpatient visits—about $12,000 in 2011 for an internist with a typical Medicare patient load and volume of office visits. The payments will be made on a quarterly basis, and will remain in effect for five years. Even with the increase, though, compensation for primary care lags well below that of other specialties. More primary care physicians also are benefiting from expanded loan forgiveness and scholarship programs available through the National Health Service Corps.

A fair assessment of the ACA to date is that it is helping millions of Americans. Improvements so far have been modest in scope, limited principally to young adults, children, seniors, primary care physicians, and some small businesses. Come 2014, 32 million Americans are expected to gain health insurance coverage, small businesses will have more options to purchase affordable health insurance, and the full range of protections against insurance practices that exclude or overcharge people with pre-existing conditions or impose annual and lifetime limits on coverage will become effective. This is unless, of course, the continued political and legal challenges to the Affordable Care Act lead to its undoing before most Americans realize its full benefits.

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