A look at healthcare: What the repeal of the ACA could mean
By Joe Paduda
Our health care system is both huge — fully one-sixth of the US economy — and very personal as it deeply affects each of us and our loved ones. The key for most of us is simple — how will possible changes affect us? Our families? Our employers? Our taxes? That’s what this column will address.
There’s been a lot of back-and-forth about the potential repeal of “Obamacare” – more accurately known as the Affordable Care Act, or ACA. The key question for most people is simple — “how would this affect me and my loved ones?”
What will happen to your premiums?
If more young people sign up, premiums for us older folks go down. But if there is no mandate and/or financial penalty for people who don’t have insurance, premiums for the 50+ crowd are going to go up – a lot. Fewer younger people, and some healthy seniors will decide the premiums are too high, so the pool of folks that buy insurance will become less healthy — and cost insurers more.
Insurers know this, so they will either a) stop selling insurance; b) raise premiums to cover potential costs; c) drastically limit coverage for specific medical conditions like heart disease or cancer; or d) go bankrupt.
Is your medical condition still covered?
ACA requires that almost all insurance plans cover all physical and mental health conditions under the essential health benefits requirement. Replacement plans under consideration have no such requirements, allowing insurance companies to exclude specific types of treatment, specific conditions, types of providers, etc.
Can insurers limit coverage for medical diagnoses or conditions?
Under ACA, there are no lifetime or annual caps for specific medical conditions. Replacement plans under consideration will allow insurers to set arbitrary caps for any diagnosis – cancer, heart disease, addiction treatment, orthopedic injuries, or any other category they define.
What happens if you lose your job and can’t afford to pay for individual health insurance while you are looking for work?
Under the replacement plans, if you have a “gap in coverage” where you don’t have health insurance, when you apply for new coverage your insurer doesn’t have to cover your pre-existing medical conditions for up to a year, and/or they can charge you higher rates.
Who pays for emergency care for those without health insurance?
Before ACA family insurance premiums included about $1,000 for the additional cost of indigent care due to cost-shifting. Hospitals charged insured people more to pay for the care of patients without insurance. If the number of people without insurance grows — as it most certainly will — they will get care at hospital emergency rooms (hospitals are required to care for anyone presenting with emergent needs regardless of insurance status). So, this “hidden tax” will almost certainly increase your premiums.
Will you be able to buy cheaper insurance from out-of-state health insurers?
No. There are three states that allow that today — and no out-of-state insurers are selling across state lines.
Joseph Paduda, principal of Health Strategy Associates, is a nationally recognized expert in medical management in group health and workers’ compensation.In addition to consulting with managed care organizations, employers, health care providers, insurers, and private equity firms, he was the 2012 recipient of IAIABC’s President’s Award, recognizing his efforts to identify solutions to the opioid problem in workers’ compensation. Before launching his consulting business in 1997, he held executive positions with major insurers, including Traveler’s, United Healthcare and Liberty Mutual. Paduda lives and works in Skaneateles.
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