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Focus On The "Essential Benefits Package" In Obamacare Now!

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Many Republicans in Congress claim they were elected to repeal the Patient Protection and Affordable Care Act, which they derisively refer to as Obamacare. The president recently said, "I don't object to that name as Obama does care!"

Republicans haven't been successful in getting the Act repealed. As of today there are two contradictory Appeals Court decisions regarding the Act. One says the 'individual mandate' forcing people to buy health insurance is constitutional, the other says it isn't. Six federal judges have ruled that it is constitutional and five that it isn't. Three other cases are awaiting appeals court decisions.

While this is being fought in the courts I would respectfully suggest to Democrats, Republicans and Independents alike that while we wait for the Supreme Court to decide, they are missing the boat if they aren't focused on the many issues being decided now at the Department of Health and Human Services (HHS) in preparation for implementation of much of the Act in 2014. In over 2,000 pages of the legislation there were untold instances where Congress punted on making a decision saying the 'Secretary shall decide'. That Secretary is Kathleen Sibelius at the Department of Health and Human Services (HHS) and decisions are being made now.

Whatever you think of the Act it is important to recognize that some of the decisions being made today at HHS will have a dramatic long-term impact on our society and the healthcare we receive. Today, healthcare costs are about 16% of the national economy with close to 50 million people still uninsured. It is crucial that we do something about this including reigning in costs and raising revenue to ensure that we can afford appropriate healthcare for everyone. One of the major decisions being made is what services will be considered as part of what Congress dubbed the 'essential health benefits package' and this includes the services that must be covered by each of the insurance plans that will want to be considered for the exchanges that states are now working to set up. It is clear that the 'essential benefits package' agreed to will impact all insurance plans both public and private.

Congress debated what should be covered by these new plans and mandated a set of 'essential benefits' categories. But it is important to recognize what actual services and items will be provided within each of these categories is being determined at HHS.

When the bill was debated there were differences in the House and Senate versions. The final bill passed was the Senate version. One example of the differences was the legislative history, which in the House version included the terms Orthotics and Prosthetics. Representative Miller (D-CA) said that "he believes that the legislative history supports the interpretation that Congress did mean to include needed orthotics and prosthetics in what was covered." He went on to say, "I am pleased that the essential benefits in the Patient Protection and Affordable Care Act include rehabilitative and habilitative devices, as these benefits are of particular importance to people with disabilities and chronic conditions. It is my understanding that the Secretary of HHS is required to develop, through regulation, standard definitions of many terms for purposes of comparing benefit categories from one private health plan to another and it is my expectation prosthetics, orthotics and related supplies will be defined separately from 'durable medical equipment'." While this isn't easy for the layman to decipher I can assure you if someone in your family has a disability or chronic disease, these definitions will be crucial to them and their ability to get appropriate care. Imagine for a moment that you have a child who either by birth or an accident doesn't have a leg and needs a prosthetic. What if that prosthesis isn't covered by insurance? This is just one example of the type of issue being debated and needing definition.

Whether you are for or against Obamacare everyone should focus on the issues that are now being decided about the care your family will receive. There is a good chance that even if the Supreme Court strikes down the individual mandate many other parts of the Act will go into effect and by the time the Court decides it may be too late for you to impact the issues you care about.

Talk to your members of Congress and make your thoughts known to the president and the Secretary of HHS about the kind of care you want your family to have. Members of the healthcare community should discuss these issues with their patients.

The private insurance industry writes insurance plans that are favorable to them. Indecipherable language that results in you finding out that you don't have coverage for a particular test or treatment only after you are told that you need it. Since Congress did mandate coverage of preventive and wellness services and a host of other categories let's make sure you will get the care you need in the future.

Republicans couldn't overturn Obamacare after they won the House of Representatives in 2010 and it will be harder now as more people take advantage of the various benefits of the bill including keeping your child on your policy till they are 26; eliminating specific caps on coverage; and making sure that pre-existing conditions don't preclude you from getting insurance.

The time is now to stop debating the entire Act and to begin influencing the parts that will directly impact you and your family.

Peter D. Rosenstein is Executive Director of the American Academy of Orthotists and Prosthetists.

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