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Linda Bergthold Headshot

Is Health Reform Exhaustion a Pre-Existing Condition?

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Is health reform exhaustion a pre-existing condition? And if so, will exhaustion be banned after health reform is passed? We can only hope. However, now that it is nearly certain that health care reform will pass, it's time to figure out what it will mean for all of us.

No, not the hype about a government takeover or the road to socialism or this is better than sliced bread. What's really in the legislation for you and when will you get it?

After the passage of the legislation, a few things will happen in the first year:

  1. Insurers can no longer put lifetime limits on your coverage. If you've never been seriously ill, this won't mean much to you, but in the case you get hit by a bus, it's surprising how quickly a million dollar lifetime limit can mount up. Now you would be covered no matter how seriously ill you get.
  2. If you are uninsured, you "may" be able to get help within 90 days from one of the state-based "high risk pools". These pools will get federal assistance to offer insurance to people with serious illnesses who have not previously been able to get insurance - I note "may" because some of these pools have long waiting lists already.
  3. Another provision for the uninsured relates to an expansion of Medicaid to adults at or below 133 percent of poverty, a provision that should kick in this year.

  4. If you have been a dependent on your parents' plan, you can stay on that plan until you turn 26 (rules vary by state but many plans only cover young adults until 23 or 24);
  5. Within six months of passage, your children cannot be denied insurance because of pre-existing conditions, and by 2014, no one can be denied because of pre-existing conditions;
  6. The so-called "donut hole" in Medicare prescription drug coverage will be eliminated - at first, reduced by500 and then ultimately closed. (If you're on Medicare you know all about this complicated provision ...)
  7. Insurers will have to spend a minimum of 80 to 85% of your monthly premium on actual medical services (not advertising, marketing, administrative costs). Why is that important? Because if you have tried to buy insurance as an individual, you may have noticed that, if you can get it, it costs a lot and the deductibles are often huge. Forcing insurers to pay out more for medical services (it's called the "medical loss ratio") is predicted to lower premiums nearly immediately.
  8. Small businesses with fewer than 25 employees would get tax credits to encourage them to purchase insurance for their employees - it might help you if you work in one of those places.
  9. Community health centers will get an immediate infusion of money from the government to help take care of people who need care but cannot afford it. Here's where you can find one near you.

What will not happen as a result of health reform, is the collapse of the health care system as we know it, despite Limbaugh's predictions. As with all major legislation, it takes awhile for change to kick in. After the first year, it will take a few years to phase in the remainder of the reform - the health insurance exchanges, the rest of the insurance reforms, changes to Medicaid (expansion of the program to include all poor adults not just women and children). There will be little if any noticeable change in Medicare - the changes that will occur will happen on the provider side, where managed care plans that serve the elderly will have to compete for business and doctors and hospitals will have to work together to figure out how to divide up Medicare payments.

Some of the more controversial elements of reform like the requirement that everyone have insurance, new taxes on Medicare for the wealthy, or taxes on companies that make medical devices, will also be phased in. It will be at least 2014 before everything is in place. It is impossible to predict how the slow pace of reform will affect opinions about health reform. Will people get frustrated if change doesn't happen quickly enough? Will opposition die down if change doesn't alter the positive elements of the health care system? Can hysterical threats of disaster maintain their intensity when there's not much disaster to identify? At the very least, we can get back to the business of trying to stay healthy without constantly hearing about health reform every day. And those of us who work in health care can get back to the business of improving the quality of health care in America.

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