A New Era in Health Care: The Affordable Care Act

By Samantha Ricketts

The recent implementation of the Affordable Care Act will impact businesses and individuals across the board. Members of different groups are beginning to see new changes in areas such as insurance and care, and many are wondering whether or not such changes will be beneficial to them.

Here, two health care professionals in the Mountain State shed some light on the facts. President and CEO of Thomas Health System, Inc., Stephen Dexter, discusses the changes taking place in hospitals, businesses and communities while Elizabeth Critch, executive director for the National Center of Excellence in Women’s Health at West Virginia University, expands on the impact that will be seen specifically by women.

A New Era in Wellness

By Stephen Dexter

The Affordable Care Act (ACA), also known as health care reform or Obamacare, is a major improvement in how health care will be delivered in America. It begins to change the process from doctors and hospitals treating people when they are ill to actually focusing on keeping them well, and it expands health insurance to the uninsured while creating a more efficient system of insurance. Overall, this shift in the way health care will be carried out in the U.S. is good for patients, good for business and good for hospitals.

Good for Patients

It’s important to understand the many ways in which the ACA will improve our country’s health care system. For starters, the ACA makes insurance more available and more affordable. This is accomplished by allowing children to stay on their parents’ health care plans up to the age of 26. Patients can no longer be denied coverage because of pre-existing conditions under the ACA, and insurance companies must spend at least 80 percent of premium dollars on actual patient care. The ACA creates insurance exchanges so patients can easily identify plans that meet their specific needs, and it provides subsidies to moderate and low-income individuals to purchase private insurance through these exchanges. In addition, it expands Medicaid to everyone under 133 percent of the poverty level with at least 93 percent of the cost covered by the federal government through 2020 while reducing the donut hole for drug costs that many Medicare recipients experience.

Equally as important as making health care more affordable, the ACA also focuses on improving patient care. This is done through incentivizing hospitals to reduce infections, falls, medical errors and repeated admissions. The ACA will also pay for many preventive services for Medicare recipients, including wellness visits, colonoscopies, mammograms and vaccinations.

Good for Business

The ACA is laden with benefits for American individuals, but they are not alone. This health care overhaul will also be good for business.

One of the biggest problems American businesses have is the rising cost of health insurance for their employees. A main reason for this is the current financing system in our country. Basically, federal and state programs pay less than the cost for treating their insured, and almost no one pays for the uninsured. Therefore, the costs of the uninsured and government program shortfalls are shifted to private payers through much higher rates. A typical business may be paying as much as 50 percent more than the actual cost of insuring their employees to cover these shortfalls. The Affordable Care Act spreads the cost of the uninsured across a much broader base, relieving some of the pressure of businesses carrying the whole burden.

As mentioned above, when businesses now buy insurance, at least 80 percent of the premium must go to medical care or the business or its employees will receive a rebate. In 2012, West Virginians received $2.7 million in rebates because of the ACA.

Good for Hospitals

There is one more group who will see the extensive benefits of the ACA: hospitals.

The ACA will actually pay hospitals for doing what they’ve always tried to do: Provide good patient care. Now if a hospital meets specific quality measures that help the patient both in the hospital and after discharge, hospitals are rewarded for providing that level of care.

In addition, more patients will get treated before they get sick. For example, 30 percent of the patients present at the St. Francis and Thomas Hospital emergency rooms are uninsured. The hospital is their last hope, and oftentimes the patients have waited much longer than advisable to seek care because they were uninsured. With the expansion of insurance coverage they will have greater access to care, and if they do end up in the emergency room, they will be more likely to have some coverage to help defray their costs.

The overall guiding principle of the Affordable Care Act is to produce better results at a lower cost. The ACA is able to accomplish this by allowing access to
the health system for almost all Americans through expanded insurance coverage, focusing on prevention and better coordination of care and paying for measurable quality. According to the Congressional Budget Office, it does so while reducing the cost to the federal budget.

While not perfect, the Affordable Care Act moves us much closer to a national system of insuring and paying for something we all need—high-quality health care.

A New Era in Women’s Health

By Elizabeth Critch

With the implementation of health reform through the Affordable Care Act (ACA), women and their families have new opportunities to improve their health and well-being. The ACA takes historic steps toward raising the importance of women’s health care and promoting awareness of what a healthy lifestyle means. The new law improves coverage of essential services for women, eliminates gender discrimination in the insurance industry and ensures access to affordable health plans regardless of employment.

From choosing the family car to selecting health care options, women make 85 percent of the important decisions for their families. Women also represent a disproportionate share of health care consumers, often managing multiple chronic conditions and paying more out-of-pocket costs, causing their health care to be prohibitively expensive and frequently unaffordable. Women routinely forgo needed services and care, either because they cannot afford it or because they simply put their family’s needs first.

Some insurance companies do not cover fundamental services women need, and many women are denied coverage outright. In West Virginia, only 1.5 percent of individual market plans cover maternity care, far below the national average of 12.5 percent. Some insurance companies even consider pregnancy a pre-existing condition. Many women who are able to purchase health insurance pay more than men for the same coverage due to a practice called gender rating. In the U.S., 92 percent of all plans use this pricing structure. The ACA attempts to change these alarming facts.

An Emphasis on Prevention

The ACA shifts emphasis from a reactive health system that responds primarily to illness and injury to a proactive one that includes a major focus on prevention. Women, in particular, will benefit from the preventive services that health plans are required to cover under the ACA with no co-pays or deductibles.

A healthy lifestyle is a journey, not a destination, and the first step is making wellness visits with a primary care provider and health screenings accessible to all women. These services will help patients develop a healthy lifestyle plan guided by the outcomes of the visit. Knowing where they are at the start of the process is key to charting their progress in adopting a healthy lifestyle.

Thanks to the ACA, not only do women have the right to select their primary and women’s health care providers within their insurance company’s network, but they now have unprecedented access to lifesaving preventive care such as:

• Well-women annual exams;

• Preventive screenings such as mammograms and screenings for cervical cancer, diabetes, blood pressure and cholesterol;

• Prenatal care and gestational diabetes screenings that help protect pregnant women from one of the most serious pregnancy-related diseases;

• FDA-approved contraceptive methods, education and counseling;

• Breastfeeding support, supplies and counseling;

• Human papillomavirus and DNA testing for women 30 or older;

• Sexually transmitted infection counseling and human immunodeficiency virus (HIV) screening and counseling;

• Flu and pneumonia shots;

• Counseling on topics such as losing weight, eating healthily, treating depression and reducing alcohol use and

• Domestic and interpersonal violence screenings and counseling.

Healthier Children and Young Adults

American children and young adults also benefit greatly from the law’s provisions. Families are able to select their children’s pediatricians, provided they are in their insurance company’s network. Routine pediatric checkups and services for healthy children are covered; oral and vision services will follow in 2014.

The ACA has already impacted the lives of millions of young adults by enabling them to remain on their parents’ health insurance policies until their 26th birthday, including those who are married or have dependent children. Until January 1, 2014, young adults who have employer-sponsored health insurance are not eligible for their parents’ policy. After that date, they can choose whichever policy is the better fit for them.

Ending Discrimination 

Until now, many Americans have been denied health care services due to most insurance companies’ pre-existing condition policies. Many people stay in jobs in which they are no longer happy because of insurance constraints. Currently, the ACA ends discrimination based on pre-existing conditions in children up to their 19th birthday.

Beginning on January 1, 2014, this provision will also be applicable to adults. Additionally, in 2014, insurance companies will no longer be allowed to charge women and small employers with a predominantly female work force more for coverage.

Addressing Public Health Concerns

The ACA places a strong emphasis on obesity and related chronic diseases, as obesity is at the root of a variety of costly health conditions. West Virginia is at the center of the U.S. obesity epidemic with the highest obesity ranking in the country: 61.5 percent of our state’s women are obese or overweight, 21 percent of our health care costs are related to obesity and we lead the nation in most obesity-related chronic diseases. Because of these persistent problems, it is estimated that West Virginia’s cost of health care in 2013 will be $2 billion, about double what it was in 2010.

According to a recent report from the National Research Council and Institute of Medicine, Americans ranked worst overall among 16 other developed countries in areas such as infant mortality, teen pregnancy, sexually transmitted diseases, HIV infection and AIDS, obesity, diabetes and heart disease.

The ACA takes enormous steps forward in promoting and protecting the health of not only women but all Americans. The law is not perfect; it is only a start. While wellness and personal responsibility are the first steps toward a healthy lifestyle, a supportive medical and payment system will allow for greater progress in improving the health of women and families.

Photography by Tracy Toler, Thomas Health System, Inc. and National Center of Excellence in Women’s Health at West Virginia University