A Common Gal Looks at ObamaCare: Part 2 — A Strangling Gordian Knot

A Common Gal Looks at ObamaCareThe Patient Protection and Affordable Care Act (“ObamaCare”) is about 1,000 pages long — about the size of two Stephen King novels. I’m reading the whole thing and commenting here — purely my own opinions. I am not a lawyer or a healthcare professional, just a common college-educated person who is willing to put in the time. I will be posting my notes here periodically when I find interesting tidbits, confusing sections, and comforting or alarming parts. Join me! Find the law here and the recent Supreme Court opinion upholding it here. If you see me getting it wrong, or if you have answers to my questions, please let me know!

We’ll Be Skipping Around

Yesterday, I mentioned that Section 2711 of ObamaCare made a complicated reference to another part of the law – Section 1302B. It sounds like that later section is going to list exceptions that DO allow insurers to cap people’s benefits each year or, in some cases, for their lifetimes. So I toodled on over to Section 1302 (B). It is clearly going to take a while to get to that information, because I’ve been reading for a couple of hours now and I still haven’t found it. Here’s what I HAVE puzzled out, though.

Lots & Lots of Healthcare Is Covered

First, it lists the categories of essential health benefits. (Smart to nail that down.) They are:

  • Ambulatory (“walk in”) patient services
  • Emergency services
  • Hospitalization
  • 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).


Coverage also can’t be “unduly” weighted toward any of the categories. Example: No fair treating someone in the ER with 100% coverage of the initial patch-up job but then paying, say, only 1% toward prosthetics and pain medicines. STILL AWESOME. (I am calling them out on the fudge factor of that weasel word, “unduly,” though.)

Ixnay on the Discrimination

The law also lists all the ways that people CANNOT be screwed out of their benefits. (My, we certainly know our legislators, healthcare institutions and insurance companies, don’t we.) I’m still working on this list, but here’s what I think it says so far:

  • The Secretary (presumably of Health and Human Services, although they sloppily did not specify) can’t do several really important things in ways that discriminate against people because of age, disability or expected length of life. Those important things include making coverage decisions, deciding reimbursement rates, creating incentive programs, and designing benefits.
  • The Secretary has to consider the needs of DIVERSE segments of the population (diverse by gender, age, disability and other ways). That seems fair. Example: Plans can’t decide only to cover the very young and extremely healthy.
  • The Secretary has to ensure that those broad categories of health benefits can’t be denied to people IF (1) that is against the people’s wishes and IF (2) the denial is based on age, expected length of life, disability, medical dependency, or quality of life. (So people can’t be told, “Hey, you’re crippled and in pain and we don’t expect you to live a long time … we’re just not going to cover you since it’s not really worth it to us.”)


Then They Wove a Tangled Web

The law next defines what it means for a health plan to “provide coverage” for those broad categories of essential health benefits. The definition is stated in the most convoluted, double-negative, conjunction-intensive sentence possible. Seriously. William Faulkner himself would have said, “WTF, can you guys not speak English?” about Section 1302(b) (4) (E) (i).

I tried to dissect it; really, I did. I *think* that the part I have read so far says this:

  • ER coverage has to be provided without requiring prior authorization.
  • Hospitals (or other ER providers) can’t limit someone’s emergency coverage just because the hospital doesn’t play well with their insurance company … UNLESS the hospital would deny coverage even for someone whose insurance company DOES have a contract with the hospital. (Believe me, that’s the simplified version.)
  • If I’m reading it correctly, it seems to say next that “out of network” co-pays for ER service can’t cost more than if the services were provided in network.

Other Posts on ObamaCare:

  • Part 1: Intro
  • Part 3: Exchanges and what they do
  • Part 4: Your cost limits and adjustments
  • Part 5: Deductibles and preventive care
  • Part 6: Four levels of coverage
  • Part 7: Limits on losing coverage

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