Several weeks of political attacks on the Affordable Care Act of 2010 have obscured the benefits of that legislation.
From 1990 to 2008, the percentage of non-elderly Americans without health insurance hovered around 16 percent. The economic recession that began in 2008 raised that figure to 18.2 percent in 2010. That year, 59 million Americans were without health insurance for at least a portion of the year. The majority were uninsured for more than one year.
In addition to uninsured persons, millions more were underinsured, holding policies that placed strict limits on coverage. They purchased insurance that offered lower premiums, an attraction to younger customers on tight budgets. Co-payments and deductibles were higher. Companies that offered these low-cost policies kept premiums low by excluding some services such as mental health care. Preventive health care such as vaccinations and cancer screening were often excluded. Maternity services might be limited as well.
A screening medical history identified people with pre-existing conditions who would be turned away.
During my years of clinical practice, I encountered patients who had purchased these bare-bones plans. Unpleasant surprises arose when they experienced illness or injury. In addition to high co-payments, they might encounter annual or lifetime limits on the amount of money that the company would pay for claims. For example, a policy might cease payment once total medical costs exceeded $100,000. If that limit were exceeded during an illness, the patient was stuck with the balance of charges for his care. These restrictions were often buried in fine print that no one read.
Limits might be included that affected payments for medications administered during a hospitalization. Higher co-payments discouraged visits to emergency rooms.
Some policies had broad definitions of what constituted pre-existing conditions. A patient might find that payment for treatment of pneumonia was denied because of a mention in his medical history that he had experienced asthma as a child. A history of chest discomfort in earlier years might be used to block payment for heart problems occurring during midlife.
High deductibles and co-payments also discouraged policyholders from seeking preventive care such as checkups, vaccinations and screenings for cancer.
Although approved by Congress and signed into law in 2010, major provisions of the ACA did not become operative until January 2014. The best summary of the ACA can be found at the Kaiser Family Foundation website (www.kff.org).
By the end of 2015, 10.5 percent of the non-elderly population were uninsured. The number of uninsured had declined to 28.5 million. Dependents could remain on the insurance plans of their parents until age 26. Federal subsidies encouraged states to increase eligibility of Medicaid programs to 138 percent of the federal poverty level. Thirty-one states and the District of Columbia chose this course.
Reform of health insurance practices is a prominent part of the ACA. Issue and renewal of health insurance policies are guaranteed. Variations in premiums are limited to age (a 3-to-1 ratio of premiums for older versus younger), family composition, region of the country and tobacco use. Pre-existing conditions do not disqualify a person from obtaining health insurance.
A range of preventive services, including addiction treatment and mental health care, are included in coverage without additional co-payment.
In an effort to gain majority support of the Senate’s Better Care Reconciliation Act (BCRA), Texas Sen. Ted Cruz offered an amendment, the Consumer Freedom Act, which would allow stripped-down health insurance plans to be marketed again. Cheaper premiums would draw younger, healthier people away from more expensive, comprehensive plans. This would create a two-tiered health insurance system. Older, sicker people could be excluded from cheaper insurance and would have only the option of more expensive, comprehensive insurance.
A joint letter from America’s Health Insurance Plans and BlueCross BlueShield Association condemned the Cruz amendment as being unworkable.
Because of opposition of four Republican senators, the BCRA has been withdrawn indefinitely. A measure to repeal the ACA and work on replacement within two years has also been shelved because of lack of majority support. The nonpartisan Congressional Budget Office estimated that this proposal would increase the number of uninsured Americans by 32 million by 2026.
As the debate over altering or replacing the ACA continues, Congress should avoid a return to deeply flawed insurance plans of the past.
Contact Clif Cleaveland at firstname.lastname@example.org.