We don't hear much about the Affordable Care Act (aka "health reform") enacted March 23, 2010 and due to be fully implemented in less than a year. But this week, on its third anniversary, there was the ritual attempt by Republicans to repeal it; some surprising turnarounds from Republican governors who decided that the 100 percent federal money for expanding Medicaid was just too good to turn down; and a few bizarre charges and (false) viral emails here and there about the devil known as "Obamacare."
But what is actually going on with health reform? Is it really going to happen? Yes it is. But it will mean different things for different people. Here's what it might mean for some of you.
1) If you work for an employer with more than 50 employees and you have insurance, you will most likely retain your insurance including preventive care at no co-pay, but your employer may decide to shift you into one of the "account-based" plans to save money. Those plans require that you pay a much higher deductible but your premiums might be lower.
2) If you work for an employer with fewer than 50 employees and have no insurance, you may be able to get insurance through one of the state "exchanges" or marketplaces, or your employer may decide to buy insurance for all employees through the exchange, but smaller employers are not required to do so.
3) If you are an adult with a pre-existing condition (whether you currently buy your own insurance or not), you will be eligible to choose insurance from a variety of options offered through the state-level exchange. That open enrollment starts in less than six months -- October of 2013. You may even be eligible for financial assistance, depending on your income level. Here is a handy calculator to help you decide if you are eligible.
4) If you are a young adult, not insured by your parents and/or in school or working without coverage and over the age of 26, you can and should buy your insurance through the exchange. There will be a penalty for each year that you do not sign up. It starts small but it gets bigger with time.
5) If you have coverage through your work and have an adult child younger than 26, your employer must offer insurance to that child under your policy now, even before the ACA is fully implemented. However, there is nothing in the law that says the coverage must be "affordable". There is protection for you as the parent if you pay more than 9.5 percent of household income in premiums, but that protection does not extend to the premiums of your dependents. This is one area of the law that is fraught with complexities and unknown consequences.
6) The rule about what "must" be covered in health plans as an "Essential Benefit" is good news for everyone. Many plans have omitted coverage for maternity or reproductive health care, mental health or substance abuse services, physical therapy or even prescription drugs. Now all those services are considered "essential" and must be offered in the health plans selling through the exchanges.
7) If you are over 65 or on Medicare, very little will change. You will continue to have your choice of supplemental or "gap" coverage or managed care plans; you will continue to get preventive services at no cost; and your prescription drug costs will continue to decline with the closure of the "doughnut hole" in Part D. Your overall benefits will not be decreased. You may pay a bit more, but that is not because of health reform. (Premiums have actually decreased in some areas in the past three years.) The Part B and Part D monthly premiums already differ depending on your income level.
8. If you are under 65 without insurance or with very expensive current insurance, health reform will benefit you most of all. Not only can you get insurance when you might have been turned down in the past, your premiums should be lower than what you have been paying in the past. That period of "waiting for Medicare" should be much less scary come 2014.
Despite the many benefits of health reform, there will be some glitches and some surprises. For example, an unusually high number of states have declined to run their own exchanges, defaulting to the federal government to do so. That may or may not be a benefit to you if you live in one of those states. (Click here to see what your state has decided.) There will be lots of confusion in the beginning, but there are federal grants to states to help them answer your questions. There will be hotlines in every state staffed by people who have been trained to answer your questions. They are public servants, so treat them kindly if they don't know every answer to every question.
And there will be a cost for health reform. There are taxes that providers must pay and penalties if you decline to get insurance. Health reform is not free. No one ever claimed it would be. Even a single payer system would not be free, although without the administrative costs of private health insurance, it might be cheaper than what we now have.
As long as we live in a country that declines to put a lid on overall health care expenditures, our costs will go up faster than any other country. If health reform works as the economists hope it will, however, overall costs will begin to flatten (and are doing so now) as more people get covered. But with fewer patients unable to pay for their care, the costs for all of us should moderate. Happy third anniversary, Health Reform.
Update: Note this summary of the good things health reform has done in the past three years.