I’m reading up on The Patient Protection and Affordable Care Act (“ObamaCare”). That includes the act itself, amendments passed shortly afterward, and the recent Supreme Court ruling. It’s a lot of pages (906, 55, and 193 respectively), but I want to understand it. I’m documenting my read-through here. I am not a lawyer or a healthcare professional, just a common college-educated person. These are my thoughts, not advice to you. Read the act yourself like the free person you are. ;o). Also note: This act refersÂ a lot to â€œhealth care plans”; for simplicityâ€™s sake, I sometimes just say â€œinsuranceâ€ or â€œhealth insurance.â€
Yesterdayâ€™s dive into the Affordable Care Act was unsatisfying because I couldnâ€™t find the text of another act thatâ€™s referenced within. But I got a little help from a friend in looking it up. ;o)
Section 1302(c)(2)(D) of the Affordable Care Act says, â€œCoordination With Preventive Limits. Nothing in this paragraph shall be construed to allow a plan to have a deductible under the plan apply to benefits described in section 2713 of the Public Health Service Act.â€
OK â€¦ so if you have health insurance under the Affordable Care Act, your deductible doesnâ€™t apply to benefits listed in Section 2713 of this other act. Sounds like I need to look up the Public Health Service Act. Hello, Google.
Well, the Public Health Service Act dates back to nineteen-freaking-forty-four and has been expanded and amended multiple times since then. Itâ€™s captured in the overwhelmingly large Title 42 of the U.S. Code, so I looked through that â€¦ and looked â€¦ and looked â€¦ and gave up and sent up a smoke signal for help. The reason I couldnâ€™t find it? Itâ€™s because itâ€™s new. Section 2713 is being added on by virtue of Section 1001 of the â€¦ you guessed it â€¦ Patient Protection and Affordable Care Act! Now why couldnâ€™t the legislators just have referred to that section within THE SAME ACT instead of sending me chasing all over the Internet? Oh, legislators â€“ quit hazing me. ;o)
Deductibles & Preventive Care
Good olâ€™ new Section 2713 is all about preventive health services. If Iâ€™m reading Section 1302(c)(2)(D) of the Affordable Care Act correctly, deductibles donâ€™t apply to the latest recommended types of preventive health services, including:
- â€œEvidence-based items or servicesâ€ (Um â€¦ isnâ€™t all medicine evidence based?)
- â€œEvidence-informed preventive care and screeningsâ€ for babies, kids and teens
- â€œAdditional preventive care and screeningsâ€ for women if the care/screening is included in comprehensive guidelines but NOT described in the actâ€™s list of essential healthcare benefits.
Section 2713 also specifies what agencies make the recommendations. The Secretary of Health and Human Services oversees the timing of when those recommendations are made vs. when the recommendations are effective.
If your eyes havenâ€™t glazed over yet, hereâ€™s one more confusing bit: All of this does NOT prevent coverage of services that go beyond those recommended, nor does it deny coverage for services that are not specifically recommended. Itâ€™s just that your deductibles donâ€™t apply (if I am reading this correctly).
Another option is troubling to me: The Secretary of Health and Human Services also can â€œdevelop guidelines to permit a group health plan and a health insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.â€ The Washington Post describes what this means:
Value-based insurance design is â€œthe idea that consumers’ out-of-pocket medical costs should be based on the value of a service to their health rather than its price.â€
Theoretical example: It might be valuable to the insurance plan for people with chronic illnesses like diabetes or high cholesterol to take preventive steps to prevent more costly problems later on, so their preventive care and medication could be free or very low cost. But expensive procedures that are deemed â€œoverusedâ€ (perhaps knee surgeries or MRI scans) could be discouraged with higher out-of-pocket costs.
Managed Care magazine said, â€œIt promotes the use of services when the clinical benefits exceed the cost and discourages the use of services when the benefits do not justify the cost.â€
I can tell you right now that this does not sound awesome to me. What it sounds like is an accountant (rather than a doctor) deciding whether a medical procedure is â€œworth itâ€ to offer to me at a reasonable price under the insurance plan.
You can read about concerns over value-based insurance in this Kaiser Health News article.
My next article will describe definitions of â€œlevels of coverageâ€ (bronze, silver, gold, and platinum) under the Affordable Care Act and why this matters.
Other Posts on ObamaCare:
- Part 1: Intro
- Part 2: Types of coverage, no discrimination
- Part 3: Exchanges and what they do
- Part 4: Your cost limits and adjustments
- Part 6: Four levels of coverage
- Part 7: Limits on losing coverage
Footnote! We’ve Got a Footnote!
 Essential healthcare benefits are listed early on in the act, and they are:
- Ambulatory (â€œwalk inâ€) patient services
- Emergency services
- Maternity/newborn care
- Mental health and substance use disorder services (including behavioral health treatment)
- Prescription drugs
- Rehab and habilitative services/devices
- Lab services
- Preventive/wellness services and chronic disease management
- Pediatric services (including oral and vision care).
2 Responses to A Common Gal Looks at ObamaCare, Part 5: Deductibles & Preventive Care
More thanks for all your hard work. You make an “eye-glazing” document understandable for humans. Plus I appreciate your dry wit. Keep it up!
Thank you so much for all your work.This is so important to our future. You made it so easy to understand..Keep up the good work