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View Diary: When All You Have Left Is 'It Could Have Been Worse' (27 comments)

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  •  Our condolences to Jim (1+ / 0-)
    Recommended by:

    but I don't understand why you wanted

    "to write a screed on the American healthcare system"
    and focus on healthcare as the issue with Jim, especially after you say:
    And here's another 'it could have been worse': Jim was found quickly, and he lived in a city with good public infrastructure (ambulances), and within two miles of one of the few hospitals in the country to be certified as a traumatic brain injury center. (Indeed, San Francisco General Hospital was the first to be so certified, in 2011.) How many people can say the same thing?

    Despite his world-class care, Jim's injuries, it quickly became clear, were going to have some lasting effects.

    Are you trying to get to how it is that, unlike Jim who lived in a city with "world-class care", before the Affordable Care Act 50 million Americans lived in Rural or Seasonal work areas which were underserved?

    Do you want to talk about all the people for whom the American Recovery and Reinvestment Act has spent the last six years building new healthcare infrastructure and improving the access to it by repairing the roads and bridges and utilities leading to it?

    Would you rather focus on how the Affordable Care Act has spent that time helping hospitals and community health centers expand by hiring, training and educating the staff and purchasing the medical equipment necessary to provide services to all those people in all those new buildings?

    Is your issue the fact that it takes a year to get onto SSI disability because Republicans think its mortal sin to take care of anybody who isn't a big enough corporation to make significant campaign contributions to them?

    Maybe you are concerned that Medicaid which helps those unfortunates who are poor and disabled providing them nursing services at home, housing, transportation, food and social services is being threatened with cuts by Republican governors despite that the Federal Government is paying 100% of the cost to get it functioning properly to support the Affordable Healthcare act?

    I'd like to hear someone address all the ways in which this affordable healthcare reform has year by year since 2010 been moving toward success with a major milestone coming next year in 2014.

    Effective at enactment

        The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.[45]
        The Medicaid drug rebate (paid by drug manufacturers to the states) for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.[45]
        A non-profit Patient-Centered Outcomes Research Institute is established, independent from government, to undertake comparative effectiveness research.[45] This is charged with examining the "relative health outcomes, clinical effectiveness, and appropriateness" of different medical treatments by evaluating existing studies and conducting its own. Its 19-member board is to include patients, doctors, hospitals, drug makers, device manufacturers, insurers, payers, government officials and health experts. It will not have the power to mandate or even endorse coverage rules or reimbursement for any particular treatment. Medicare may take the Institute's research into account when deciding what procedures it will cover, so long as the new research is not the sole justification and the agency allows for public input.[46] The bill forbids the Institute to develop or employ "a dollars per quality adjusted life year" (or similar measure that discounts the value of a life because of an individual's disability) as a threshold to establish what type of health care is cost effective or recommended. This makes it different from the UK's National Institute for Health and Clinical Excellence.
        Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.[45]
        The Indian Health Care Improvement Act is reauthorized and amended.[45]
        Chain restaurants and food vendors with 20 or more locations are required to display the caloric content of their foods on menus, drive-through menus, and vending machines. Additional information, such as saturated fat, carbohydrate, and sodium content, must also be made available upon request.[47] But first, the Food and Drug Administration has to come up with regulations, and as a result, calories disclosures may not appear until 2013 or 2014.[dated info][47]
        States can apply for a 'State Plan Amendment" to expand family planning eligibility to the same eligibility as pregnancy related care (above and beyond Medicaid level eligibility), through a state option rather than having to apply for a federal waiver.[48][49][50]

    Effective June 21, 2010

        Adults with existing conditions became eligible to join a temporary high-risk pool, which will be superseded by the health care exchange in 2014.[42][51] To qualify for coverage, applicants must have a pre-existing health condition and have been uninsured for at least the past six months.[52] There is no age requirement.[52] The new program sets premiums as if for a standard population and not for a population with a higher health risk. Allows premiums to vary by age (3:1), geographic area, family composition and tobacco use (1.5:1). Limit out-of-pocket spending to $5,950 for individuals and $11,900 for families, excluding premiums.[52][53][54]

    Effective July 1, 2010

        The President established, within the Department of Health and Human Services (HHS), a council to be known as the National Prevention, Health Promotion and Public Health Council to help begin to develop a National Prevention and Health Promotion Strategy. The Surgeon General shall serve as the Chairperson of the new Council.[55][56]
        A 10% sales tax on indoor tanning took effect.[57]

    Effective September 23, 2010

        Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.[58]
        Dependents (children) will be permitted to remain on their parents' insurance plan until their 26th birthday,[59] and regulations implemented under the PPACA include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.[60][61]
        Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.[62][63]
        All new insurance plans must cover preventive care and medical screenings[64] rated Level A or B by the U.S. Preventive Services Task Force.[65] Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.[66]
        Individuals affected by the Medicare Part D coverage gap will receive a $250 rebate, and 50% of the gap will be eliminated in 2011.[67] The gap will be eliminated by 2020.
        Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.[42]
        Insurers are prohibited from dropping policyholders when they get sick.[42]
        Insurers are required to reveal details about administrative and executive expenditures.[42]
        Insurers are required to implement an appeals process for coverage determination and claims on all new plans.[42]
        Enhanced methods of fraud detection are implemented.[42]
        Medicare is expanded to small, rural hospitals and facilities.[42]
        Medicare patients with chronic illnesses must be monitored/evaluated on a 3-month basis for coverage of the medications for treatment of such illnesses.
        Companies which provide early retiree benefits for individuals aged 55–64 are eligible to participate in a temporary program which reduces premium costs.[42]
        A new website installed by the Secretary of Health and Human Services will provide consumer insurance information for individuals and small businesses in all states.[42]
        A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.[42]
        All new insurance plans must cover childhood immunizations and adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) without charging co-payments, co-insurance, or deductibles when provided by an in-network provider.[68]

    Effective January 1, 2011

        Insurers must spend 80% (for individual or small group insurers) or 85% (for large group insurers) of premium dollars on health costs and claims, leaving only 20% or 15% respectively for administrative costs and profits, subject to various waivers and exemptions. If an insurer fails to meet this requirement, there is no penalty, but a rebate must be issued to the policy holder. This policy is known as the 'Medical Loss Ratio'.[69][70][71][72]
        The Centers for Medicare and Medicaid Services is responsible for developing the Center for Medicare and Medicaid Innovation and overseeing the testing of innovative payment and delivery models.[73]
        Flexible spending accounts, Health reimbursement accounts and health savings accounts cannot be used to pay for over-the-counter drugs, purchased without a prescription, except insulin.[74]

    Effective September 1, 2011

        All health insurance companies must inform the public when they want to increase health insurance rates for individual or small group policies by an average of 10% or more. This policy is known as 'Rate Review'. States are provided with Health Insurance Rate Review Grants to enhance their rate review programs and bring greater transparency to the process.[75][76]

    Effective January 1, 2012

        Employers must disclose the value of the benefits they provided beginning in 2012 for each employee's health insurance coverage on the employee's annual Form W-2's.[77] This requirement was originally to be effective January 1, 2011, but was postponed by IRS Notice 2010–69 on October 23, 2010.[78] Reporting is not required for any employer that was required to file fewer than 250 Forms W-2 in the preceding calendar year.[79]

        New tax reporting changes were to come in effect. Lawmakers originally felt these changes would help prevent tax evasion by corporations. However, in April 2011, Congress passed and President Obama signed the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 repealing this provision, because it was burdensome to small businesses.[80][81] Before the PPACA, businesses were required to notify the IRS on form 1099 of certain payments to individuals for certain services or property over a reporting threshold of $600.[82][83] Under the repealed law, reporting of payments to corporations would also be required.[84][85] Originally it was expected to raise $17 billion over 10 years.[86] The amendments made by Section 9006 of the PPACA were designed to apply to payments made by businesses after December 31, 2011, but will no longer apply because of the repeal of the section.[81][83]

    Effective August 1, 2012

        All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services – including: well-woman visits; gestational diabetes screening; human papillomavirus (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling - will be covered without cost sharing.[87] This is also known as the contraceptive mandate.[64][88][89]

    Effective October 1, 2012

        The Centers for Medicare & Medicaid Services (CMS) will begin the Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. The regulations that implement this provision are in subpart I of 42 CFR part 412 (§412.150 through §412.154).[90] Starting in October, an estimated total of 2,217 hospitals across the nation will be penalized; however, only 307 of these hospitals will receive this year's maximum penalty, i.e., 1 percent off their base Medicare reimbursements. The penalty will be deducted from reimbursements each time a hospital submits a claim starting Oct. 1. The maximum penalty will increase after this year, to 2 percent of regular payments starting in October 2013 and then to 3 percent the following year. As an example, if a hospital received the maximum penalty of 1 percent and it submitted a claim for $20,000 for a stay, Medicare would reimburse it $19,800. Together, these 2,217 hospitals will forfeit more than $280 million in Medicare funds over the next year, i.e., until October 2013, as Medicare and Medicaid begin a wide-ranging push to start paying health care providers based on the quality of care they provide. The $280 million in penalties comprises about 0.3 percent of the total amount hospitals are paid by Medicare.[91]

    Effective January 1, 2013

        Income from self-employment and wages of single individuals in excess of $200,000 annually will be subject to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to joint compensation of the two spouses), or $125,000 for a married person filing separately.[92] In addition, an additional Medicare tax of 3.8% will apply to unearned income, specifically the lesser of net investment income or the amount by which adjusted gross income exceeds $200,000 ($250,000 for a married couple filing jointly; $125,000 for a married person filing separately.)[93]

        Beginning January 1, 2013, the limit on pre-tax contributions to healthcare flexible spending accounts will be capped at $2,500 per year.[94][95][96]

        Most medical devices become subject to a 2.3% excise tax collected at the time of purchase. (Reduced by the reconciliation act from 2.6% to 2.3%.)[97] This tax will also apply to some medical devices, such as examination gloves and catheters, that are used in veterinary medicine.[98]

        Insurance companies are required to use simpler, more standardized paperwork, with the intention of helping consumers make apples-to-apples comparisons between the prices and benefits of different health plans.[99]

    The following stuff hasn't happened yet but within the next few months the next wave of reforms will come to play
    Effective by August 1, 2013

        Religious organizations that were given an extra year to implement the contraceptive mandate are no longer exempt. Certain non-exempt, non-grandfathered group health plans established and maintained by non-profit organizations with religious objections to covering contraceptive services may take advantage of a one-year enforcement safe harbor (i.e., until the first plan year beginning on or after August 1, 2013) by timely satisfying certain requirements set forth by the U.S. Department of Health & Human Services.[100]

    Effective by October 1, 2013

        Starting in October 2013, those looking to buy individual health insurance can enroll in subsidized plans offered through state-based exchanges (see below), with coverage beginning in January 2014.[101][102][103]
    Effective by January 1, 2014
    Maximum Out-of-Pocket Premium Payments Under PPACA by Family Size and federal poverty level.[13] (Source: CRS)

        Insurers are prohibited from discriminating against or charging higher rates for any individual based on gender or pre-existing medical conditions.[104]
        Insurers are prohibited from establishing annual spending caps.[42]
        Individuals who are not covered by an acceptable insurance policy will be charged an annual penalty of $95, or up to 1% of income over the filing minimum,[105] whichever is greater; this will rise to a minimum of $695 ($2,085 for families),[106] or 2.5% of income over the filing minimum,[105] by 2016.[19][107] Exemptions to the mandatory coverage provision and penalty are permitted for religious reasons, members of health care sharing ministries, or for those for whom the least expensive policy would exceed 8% of their income.[108]
        In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.[19][109] As written, the PPACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled, in National Federation of Independent Business v. Sebelius, that this withdrawal of funding was unconstitutionally coercive, and that individual states had the right to opt out of the Medicaid expansion without losing pre-existing Medicaid funding from the federal government. As of April 25, 2013, fifteen states—Alaska, Alabama, Georgia, Idaho, Indiana, Iowa, Louisiana, Mississippi, Nebraska, North Carolina, Oklahoma, South Carolina, Texas, Wisconsin, and Virginia—were not participating in the Medicaid expansion, with ten more—Kansas, Maine, Michigan, Montana, Missouri, Ohio, Pennsylvania, South Dakota, Utah, and Wyoming—leaning towards not participating.[110]
        Health insurance exchanges are established, and subsides for insurance premiums are given to individuals who buy a plan from an exchange and have a household income between 133% and 400% of the poverty line. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage.[109][111][112][113] Section 1401(36B) of PPACA explains that each subsidy will be provided as an advanceable, refundable tax credit[114] and gives a formula for its calculation.[115] A refundable tax credit is a way to provide government benefits to individuals who may have no tax liability[116] (such as the Earned Income Tax Credit). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. The U.S. Department of Health and Human Services (DHHS) and Internal Revenue Service (IRS) on May 23, 2012, issued joint final rules regarding implementation of the new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.[117][118] According to DHHS and CRS, in 2014 the income-based premium caps for a "silver" healthcare plan for a family of four will be the following:

    Health Insurance Premiums and Cost Sharing under PPACA for Average Family of 4[13][118][119][120][121] Income % of federal poverty level     Premium Cap as a Share of Income     Income $ (family of 4)a     Max Annual Out-of-Pocket Premium     Premium Savingsb     Additional Cost-Sharing Subsidy
    133%     3% of income     $31,900     $992     $10,345     $5,040
    150%     4% of income     $33,075     $1,323     $9,918     $5,040
    200%     6.3% of income     $44,100     $2,778     $8,366     $4,000
    250%     8.05% of income     $55,125     $4,438     $6,597     $1,930
    300%     9.5% of income     $66,150     $6,284     $4,628     $1,480
    350%     9.5% of income     $77,175     $7,332     $3,512     $1,480
    400%     9.5% of income     $88,200     $8,379     $2,395     $1,480

    a.^ Note: In 2016, the FPL is projected to equal about $11,800 for a single person and about $24,000 for family of four.[122][123] See Subsidy Calculator for specific dollar amount.[124] b.^ DHHS and CBO estimate the average annual premium cost in 2014 to be $11,328 for family of 4 without the reform.[119]

        Section 2708 to the Public Health Service Act becomes effective, which prohibits patient eligibility waiting periods in excess of 90 days for group health plan coverage. The 90-day rule applies to all grandfathered and non-grandfathered group health plans and group health insurance issuers, including multiemployer health plans and single-employer group health plans pursuant to collective bargaining arrangements.[125] Plans will still be allowed to impose eligibility requirements based on factors other than the lapse of time; for example, a health plan can restrict eligibility to employees who work at a particular location or who are in an eligible job classification. The waiting period limitation means that coverage must be effective no later than the 91st day after the employee satisfies the substantive eligibility requirements.[126]
        Two years of tax credits will be offered to qualified small businesses. To receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full-time equivalent ("FTE") employee of no more than $50,000 and have no more than 25 FTEs. For the purposes of the calculation of FTEs, seasonal employees, and owners and their relations, are not considered. The subsidy is reduced by 3.35 percentage points per additional employee and 2 percentage points per additional $1,000 of average compensation. As an example, a 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.[127]
        A $2,000 per employee penalty will be imposed on employers with more than 50 employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill).[30] "Full-time" is defined as, with respect to any month, an employee who is employed on average at least 30 hours of service per week.[128]
        For employer-sponsored plans, a $2,000 maximum annual deductible is established for any plan covering a single individual or a $4,000 maximum annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302.
        To finance part of the new spending, spending and coverage cuts are made to Medicare Advantage, the growth of Medicare provider payments are slowed (in part through the creation of a new Independent Payment Advisory Board), Medicare and Medicaid drug reimbursement rates are decreased, and other Medicare and Medicaid spending is cut.[44][129]
        Revenue is increased from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.[130]
        Members of Congress and their staff are only offered health care plans through the exchange or plans otherwise established by the bill (instead of the Federal Employees Health Benefits Program that they currently use).[131]
        A new excise tax goes into effect that is applicable to pharmaceutical companies and is based on the market share of the company; it is expected to create $2.5 billion in annual revenue.[107]
        Health insurance companies become subject to a new excise tax based on their market share; the rate gradually rises between 2014 and 2018 and thereafter increases at the rate of inflation. The tax is expected to yield up to $14.3 billion in annual revenue.[107]
        The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of adjusted gross income (AGI).[132]
        Consumer Operated and Oriented Plans (CO-OP), which are member-governed non-profit insurers, entitled to a 5-year federal loan, are permitted to start providing health care coverage.[133]
        The CLASS Act provision would have created a voluntary long-term care insurance program, but in October 2011 the Department of Health and Human Services announced that the provision was unworkable and would be dropped.[134] The CLASS Act was repealed January 1, 2013.[135]

    Effective by October 1, 2014

        Federal payments to so-called 'disproportionate share hospitals', which treat large numbers of indigent patients, are to be reduced and subsequently allowed to rise based on the percentage of the population that is uninsured in each state.[136]
    Effective by January 1, 2015

        CMS begins using the Medicare fee schedule to give larger payments to physicians who provide high-quality care compared with cost.[137]

    Effective by October 1, 2015

        States are allowed to shift children eligible for care under the Children's Health Insurance Program to health care plans sold on their exchanges, as long as HHS approves.[136]

    Effective by January 1, 2016

        States are permitted to form health care choice compacts and allows insurers to sell policies in any state participating in the compact.[136]
        The threshold for itemizing medical expenses increases from 7.5% of income to 10% for seniors.[138]

    Effective by January 1, 2017

        A state may apply to the Secretary of Health & Human Services for a "waiver for state innovation" provided that the state passes legislation implementing an alternative health care plan meeting certain criteria. The decision of whether to grant the waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period.[139] A state receiving the waiver would be exempt from some of the central requirements of the ACA, including the individual mandate, the creation by the state of an insurance exchange, and the penalty for certain employers not providing coverage.[140][141] The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, but which cannot be paid out due to the structure of the state plan.[139] To qualify for the waiver, the state plan must provide insurance at least as comprehensive and as affordable as that required by the ACA, must cover at least as many residents as the ACA plan would, and cannot increase the federal deficit. The coverage must continue to meet the consumer protection requirements of the ACA, such as the prohibition on increasing premiums because of pre-existing conditions.[142] A bipartisan bill sponsored by Senators Ron Wyden and Scott Brown, and supported by President Obama, proposes making waivers available in 2014 rather than 2017, so that, for example, states that wish to implement an alternative plan need not set up an insurance exchange only to dismantle it a short time later.[140] In April 2011 Vermont announced its intention to pursue a waiver to implement the single-payer system enacted in May 2011.[143][144][145][146] In September 2011 Montana announced it would also be seeking a waiver to set up its own single payer healthcare system.[147]
        States may allow large employers and multi-employer health plans to purchase coverage in the Exchange.
        Two federally regulated 'multi-state plan' (MSP) insurers, with one being non-profit and the other being forbidden from providing coverage for abortion services, will be available to all states. They will have to abide by the same federal regulations as required by individual state's qualified health plans available on the exchanges and must provide the same identical cover privileges and premiums in all states. MSPs will be phased in nationally, being available in 60% of all states in 2014, 70% in 2015, 85% in 2016 with full national coverage in 2017.[148]

    Effective by January 1, 2018

        All existing health insurance plans must cover approved preventive care and checkups without co-payment.[42]
        A 40% excise tax on high cost ("Cadillac") insurance plans is introduced. The tax (as amended by the reconciliation bill)[149] is on insurance premiums in excess of $27,500 (family plans) and $10,200 (individual plans), and it is increased to $30,950 (family) and $11,850 (individual) for retirees and employees in high risk professions. The dollar thresholds are indexed with inflation; employers with higher costs on account of the age or gender demographics of their employees may value their coverage using the age and gender demographics of a national risk pool.[107][150]

    Effective by January 1, 2019

        Medicaid extends coverage to former foster care youths who were in foster care for at least six months and are under 25 years old[48]

    Effective by January 1, 2020

        The Medicare Part D coverage gap (a.k.a., "donut hole") will be completely phased out and hence closed.

    Live Free or Die --- Investigate, Incarcerate

    by rktect on Sat May 25, 2013 at 03:39:54 AM PDT

    [ Parent ]

    •  Thanks (0+ / 0-)

      for explaining the health (ACA) care law in everyday language. I know when I read the actual text of the law it could be confusing.

      Maybe more people will read and understand it, and how it applies. I've talked to some people (including my daughter), who have misinterpreted or listened to others'  versions, who have no idea how it works. when my daughter kept raising objections, I had to keep telling her"It's not in there." Few people wanted to take the time to read it themselves. It's important that people understand it, since fine tuning will still probably be necessary.

      Great diary!

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