What does the Affordable Care Act mean for diabetes care?

The next phase of the Patient Protection and Affordable Care Act (ACA, "Obamacare") will go into effect starting October 1, 2013, when the Health Insurance Marketplace goes live.  From what I gather, it will be kind of like shopping online for car insurance, but for health coverage.  I was hoping to be able to write something specific about what the coverage means for people with diabetes, but those details are not available yet.  I think that will depend entirely on which coverage you or your employer buys.

Given that the open enrollment period begins in just a few weeks, I'm a bit dismayed by the lack of concrete information.  A lot of people who are currently uninsured receive discounts or free medications through Patient Assistance Programs and they have access to free or low cost health clinics that are designated for the uninsured.  But what sort of affordable coverage will be there for these folks who have historically been uninsured or under-insured?  Will the out of pocket costs of diabetes medications be even higher for folks who might no longer qualify for Patient Assistance Programs?

The ACA is so complicated that I even though I read policy jargon all the time, I had to re-read even the summaries several times to get the main points, especially around penalties and fees. Here's what I have figured out so far:

Download the PDF at https://dl.dropboxusercontent.com/u/6989183/PPACADownload.pdf

What it means for you:

• You have to purchase health insurance, either through your employer or the Health Insurance Marketplace.  You cannot be denied new coverage due to pre-existing conditions.

• If you don't purchase insurance, then you will receive a 2014 tax penalty of the greater $95 for an individual/$285 for a family or 1% of the household income.  This will increase to $325/975 or 2% for 2015 and $695/$2,085 or 2.5% in 2016.  Beyond 2016, it will adjust for inflation.

• You are exempt from penalties if you earn too little to file a federal tax return (below $9,530 for singles and $18,700 for couples) or the lowest price plan exceeds 8% of your income.

• If you do not like or cannot afford the insurance plan your employer offers, you can purchase insurance through the marketplace instead.

• If you earn 133-400% of the Federal Poverty Line (FPL), then you will qualify for government subsidies for premiums and cost-sharing for plans purchased through the marketplace.  The 2013 FPL (in the contiguous 48 states and Washington DC) for an individual is $11,490 and it is $23,550 for a family of four.

• You may qualify for Medicaid even if you didn't before (for example, if you are a single, child-free adult living near the FPL) if it is expanded in your state.  If your state does not expand Medicaid, there might be a state Basic Health Plan for you if you earn 133-200% of the FPL.  If you receive Medicaid or participate in a state Basic Health Plan, then you would not receive the subsidy.

• If your insurance company mis-spends your premiums on stuff other than health care services, you will receive a refund.

Since I wasn't getting anywhere with specific policy coverage, I then tried to figure out what is included in the minimum essential benefits that qualifying health care coverage is supposed to deliver.  All I have found are discussions that center around how frustratingly obtuse the legislation is and ways that employers might exploit loopholes by offering inadequate coverage and not reporting their compliance activities.  Even descriptions of the Basic Health Plans that states could offer in lieu of expanding Medicaid do not give any meaningful details.  

The U.S. Supreme Court ruled that the individual mandate to buy health insurance is constitutional, so in order to reduce the burden on low income individuals, Medicaid has been expanded.  However, since Medicaid is administered by the states, it is up to them to decide whether to expand that coverage.  This means that states that do not expand Medicaid eligibility per the federal guidelines will also not receive the additional federal monies, leaving many low income, working people uninsured due to their inability to afford insurance coverage through the health insurance exchanges.  They would be exempt from tax penalties for being uninsured, but they also would disproportionately bear the risk of devastating medical expenses in the event of serious illness or injury and they would not benefit from the discounted negotiated rates for services and prescription drugs that members of group plans enjoy.

So what does all of this mean for people with diabetes?

My informed, though unscientific, guess is that more people will have insurance and so they will use preventive health care services.  There should also be higher numbers of office visits which will hopefully reduce emergency room visits.  The ACA could be great for people who have had earnings above the thresholds for Patient Assistance Programs and government programs, but who could not get insurance due to lack of employer sponsored coverage or the pre-existing conditions clauses.  Of course all of this assumes that there are enough physicians who are taking new patients and who will accept the new insurance plans for payment to handle the increased numbers of patients.

Another issue is that there are some ways that practitioners are limited in what they can do if they are billing for it.  For example, in some free clinics for the uninsured, diabetes education and nutritional counseling are unlimited.  In clinics where patients are insured, the availability of those services depends on how much the insurance will cover.  I suspect that instead of expanding these critically necessary services for diabetes care, it will impose tighter limits across the board (for example, many insurance companies will cover three group diabetes education classes the first year of diagnosis).  The best we can hope for is that educational, nutritional and behavioral services for people with diabetes will included as unlimited preventive health care services under the basic health plans.

It is also hard to say what will happen to the affordability of medications and testing supplies.  I suspect that on the whole there will be greater access to a broader range of drugs for middle-income folks, but that the out of pocket costs will still severely limit what is accessible for individuals and families that are struggling to make ends meet.  There are some ways in which having too little prescription drug coverage is worse than having none at all when pharmaceutical companies are willing to subsidize or provide drugs free of charge for the uninsured.

I am cautiously hopeful that this health insurance reform can increase health and well-being in our society. I am also very skeptical and wishing we could have real health care reform.