ENTtoday

Health Reform to Insure 32 Million: Are you ready for them?

by Geri Aston •

APRIL 2010: States can expand Medicaid to childless adults up to 133 percent of the federal poverty level (FPL).

JUNE 2010: Temporary state high-risk pools for uninsured people with preexisting conditions are to begin.

  • Temporary reinsurance program for early retirees is to begin.

SEPTEMBER 2010: Health plans can’t impose lifetime limits or unreasonable annual limits on dollar value of coverage.

  • Insurers can’t rescind coverage, except for enrollee fraud.
  • Insurers must cover dependents up to age 26.

2013: The federal government creates Consumer Operated and Oriented Plan program to foster creation of non-profit, member-run health insurers.

2014:

  • States must expand Medicaid to all non-Medicare eligible individuals with incomes up to 133 percent of the FPL.
  • Insurers can’t impose preexisting condition exclusions.
  • Premium rates can only vary depending on family size, rating area, age and tobacco use.
  • Guaranteed availability and renewability of individual and group coverage begins.
  • Individual health insurance mandate begins.
  • Sliding-scale subsidies that cap health insurance premiums and cost-sharing at a percentage of household income become available for individuals below 400 percent of the FPL.
  • •Guaranteed availability and renewability of individual and group coverage begins.
  • Sliding-scale subsidies that cap health insurance premiums and cost-sharing at a percentage of household income become available for individuals below 400 percent of the FPL.

2015: State-based insurance exchanges must be self-sustaining.

2017: States must pay a share of the new mandatory Medicaid expansion.

2018: Excise tax on employer-sponsored “Cadillac” health plans kicks in.

Sources: Patient Protection and Affordable Care Act, Kaiser Family Foundation, National Governors Association

What the Bill Doesn’t Address

While the act includes many laudable changes, the provisions it lacks raise much concern, says Gavin Setzen, MD, chair of the American Academy of Otolaryngology—Head and Neck Surgery Board of Governors. A major disappointment for physicians is lawmakers’ failure to pass Medicare payment reform as part of the law. Although, in April, Congress again delayed the 21 percent Medicare physician payment cut, this time until June 1, it has not replaced what physicians consider a flawed reimbursement formula.

The financial pressure physicians would face if the Medicare cut occurs would worsen a projected physician shortage, Dr. Setzen said. The Association of American Medical Colleges predicts the U.S. will have between 124,000 and 159,000 too few physicians by 2025.

A recent survey of more than 14,000 surgeons and anesthesiologists by the American College of Surgeons found that 37 percent will change their Medicare status to nonparticipating if the cut goes through, and 29 percent will opt out of the program for two years and privately contract with Medicare patients. Of the 31 percent of respondents who plan to continue Medicare participation, three-fourths plan on making some change in their practice in the next 12 months. Sixty-nine percent plan to limit the number of Medicare patient appointments.