Hidden Nuggets in the Health Reforms

06/27/2010 09:29 pm ET | Updated May 25, 2011

The final health reform law is much too long, more than 2,000 pages, mostly because of dozens of compromises to get Democrats (liberals and conservatives) on board, and in a vain effort to get support from Republicans who marched in lockstep to vote no like, say, the goosestepping North Korean army.

Nevertheless, a 2,000-page bill is not unusual for even routine legislation like the budget, but the length reflects these contentious days in the Congress, especially for such a massive and comprehensive legislative enterprise as the historic Patient Protection and Affordable Care Act.

Most of us know, or will soon see, the main benefits, requiring insurance and drug companies to provide -- with the government's help -- affordable health care and prescription drug for 40 million uninsured Americans, including children, no matter their current health problems. In fact, beginning July 1, many states will be offering health insurance at competitive prices (with federal help) to uninsured high risk people who have pre-existing conditions that have prevented them from getting coverage.

But in reviewing the bill and the analyses of various organization, the PPACA, as it has become known, also includes some valuable unpublicized benefit nuggets. For example, the June AARP Bulletin tells me than the law has set aside $2 billion over five years to encourage states to use Medicaid dollars to help older people "transition" out of nursing homes to more independent living arrangements-their homes or assisted living. These patients ought to know about this and take advantage of it; best to stay home or in your community.

Preventive medicine also will be a high priority in the law, from which you'll benefit in coming years. Just last week, Health and Human Services Secretary Kathleen Sibelius announced the law will allocate $250 million for public health initiatives on preventing and dealing with chronic diseases, including curbing tobacco and alcohol abuse (something the British health system is tackling).

She wants to spend the money training hundreds of needed primary care doctors, but lawmakers want more spent on preventive medicine. This is part of the $500 million Prevention and Public Health Fund, the first of its kind under Medicare, created by the act. Money will be available, through grants, to community clinics, hospitals, and researchers.

If you didn't already know, beginning next year, all preventive screening and tests for Medicare patients-mammograms, colonoscopies and annual comprehensive physical exams will be free. Private insurers are expect to follow suit.

One of my favorite obscure provisions is in section 4207, which requires employers to "provide a reasonable break time for an employees to express breast milk for her nursing child for one year after the child's birth: and to provide a place, not a bathroom for mother to nurse the child." Other benefits are enhanced for infant care.

The respected Center for Medicare Advocacy has compiled a number of important, but obscure provisions of the reforms. Beginning next year, Medicare Advantage Prescription Drug plans may not manipulate premiums for low-income beneficiaries in order to force them into other plans.

But the HHS Secretary is authorized to auto-enroll low-income beneficiaries who have lost their plans into more advantageous plans. Effective Jan. 1, an individual whose spouse dies in the middle of a low-income eligibility period is granted continued eligibility for a full year beyond the date when his/her eligibility would end. Of course he/she could reapply for the low income benefits. You should check with the center to see if you qualify as low-income.

"Dual eligibles," low-income individuals who are eligible for both Medicaid (health care for the poor) and Medicare, have always presented the Centers for Medicare and Medicaid Services (CMS) with bureaucratic problems. The Republican Part D law, took away availability for cheap medicines from Medicaid beneficiaries and forced them to use more expensive and limited Medicare Part D, with its co-pays, limitations and the notorious donut hole. Low income people can get "extra help" in paying for drugs. And the donut hole is to be phased out slowly. If you fell into the hole, you should have gotten a $250 rebate. That's a pittance, but the next big change comes next year when the cost of brand named drugs, while you're in the hole will be cut by 50 percent.

(A reader asks why the Republican Congress in 2003 created the donut hole, in which the beneficiary must pay the full, retail cost of his drug. This year the beneficiary who has purchased $2,830 in drugs, at the cost of small co-pays, must pay, while in the hole, the full price until he/she reaches $4,300 in out of pocket costs. The Congress created the hole, which has grown larger each year based on the economic theory called '"moral hazard," which means beneficiaries will buy more drugs that they may not need if there were no such curbs as the donut hole. Put another way, persons with good auto insurance are more likely to drive recklessly and have accidents. For the Republican sponsors it was there way of saving money by forcing beneficiaries to pay more out of pocket.)

Anyway, the problems of dual eligibles will be assigned to a new Federal Coordinated Care Office, to integrate benefits under Medicaid and Medicare and, under the law, to provide dual eligibles "full access to all benefits of both programs." Too often the elderly poor who are on Medicare do not get the full benefits of Medicaid, if they are under home care or in a nursing facility.

More specifically for dual eligibles, effective Jan. 1, 2012, the reforms call for the elimination of cost-sharing (co-pays) for Part D drugs, for all full benefit dual-eligible beneficiaries, who are receiving Medicaid and Medicare at home or on a nursing institution. The center says "This provision creates equity in Part D cost sharing between those in institutions and those getting substantially the same services" at home or in assisted living.

Long Term Care remains, as AARP said, the greatest unmet health care need in the country. Perhaps two thirds of people who are 65 today will need long term care, at home or in an institutional setting. The U.S. spends $207 billion on long term care, much of it on Medicaid funds which are used by many middle and working class families who game the system by transferring their assets to loved one, impoverishing themselves in order to become eligible.

They should not be condemned for they have little choice; long term care insurance is expensive and few will spend years paying the premiums for insurance they probably won't need. Only 7 million Americans have long term care insurance; it's not feasible for a person who is, say 60, to pay for 20 years on the chance he/she will need it. If it's not needed, the money is lost. And often the insurance companies, several of which have been absorbed by conglomerates, will raise premiums when the elderly beneficiary can least afford it.

According to the center, the reforms call for better regulate the thousands of nursing facilities, some of which have been literally getting away with murder, neglecting residents mostly because of poorly paid, insufficient staffs. There are perhaps a dozen provisions policing nursing homes to hold them accountable for maltreatment of patients. Medicare, of course, covers medical needs of nursing home patients, but after 20 to 100 (expensive days) in rehabilitation after a hospitalization, say for a hip replacement, it does not cover long term nursing home care. Medicaid does, but the Congress has been cracking down on those who get rid of their money to get the Medicaid benefits.

The reforms, thanks to the late Sen. Edward M. Kennedy, include the modest Community Assistance Services and Supports Act (CLASS), under which employees may voluntarily sign up to contribute $50 a month into a fund, which eventually will pay a tiny fraction of the current $150 per day, rate for a good nursing home. It's an obscure provision of the massive health reforms. And it means less than minimal progress in dealing with long term care.

Maybe it deserves obscurity, for while some say it's a start; I say it's a shame. The congress and President Obama, who speaks of his late grandmother in long term care, could have done more. Where is the real concern for older Americans, the fastest growing part of the population?

Finally, for the best and latest information on the 2,000 pages of the PPACA, try this site.

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