top of page

Healthcare...It's Complicated

“It’s complicated” - One of the truer statements made by Donald Trump during the tumultuous days of his presidency. He asked: “Who knew…?” Well, the answer to that is that most of us have known how complicated healthcare is for many years. During the past few decades there have been so many contradictory views and opinions on healthcare, but the amount of misinformation that has been presented as fact in political ads, debates, and through the media in the past few years has been unprecedented, leaving the majority of us confused and overwhelmed.

If you can turn down the noise and sift through the data, there are many sources of valid, accurate information to be found. The Department Health and Human Services, the Senate Office of Public Records,, and the Affordable Care Act (ACA) itself are some of the more reliable sources of information to help shed some light on what the Affordable Care Act (Obamacare), and the now withdrawn American Health Care Act (Trump’s repeal and replace fiasco) actually offer or provide.

The original intent of the ACA was to provide health insurance to all Americans (including the 45-55 million Americans who had no coverage previously) and to maintain our “free market” system instead of going to a single payer system like all the other industrialized countries in the world. In order to level the playing field in the marketplace it was determined that there must be basic requirements or provisions in all health plans offered. Key provisions are listed below:

  • No lifetime or annual limits on claims paid

  • No rescission of coverage except for fraud or misrepresentation

  • Coverage for preventive services without cost sharing

  • Extension of dependent coverage up to age 26 without regard to employment, student or marital status

  • Development of uniform explanation of benefits and definitions

  • No discrimination based on wages/salary for full-time employees

  • Eliminate pre-existing condition clauses/coverage determinations

  • Guaranteed availability of coverage

  • Require insurers to implement effective appeals processes

  • Require publicly held companies to report total premium revenue and the amount of non-claim costs not to exceed 20% for group markets and 25% for individual markets, with excess costs to be refunded to enrollees (this expired 12/31/2013 and was not renewed by Congress)

  • Ensure Quality of Care guidelines be developed with program initiatives to improve health outcomes through care coordination, chronic disease management, prevention of hospital readmissions, improvement in patient safety, and promote health and wellness.

  • Provide re-insurance for early retirees ages 55-64 funded wit $5billion until expended.

  • Establish Internet Portal for consumers to access affordable and comprehensive coverage options (this took some significant tweaking to make it functional)

  • Reduce clerical burden on providers, patients, and plans.

Subsequent Provisions included:

  • Fair Health Insurance Premiums only allowing variances on family structure, geography, actuarial value of benefit, age (limited ratio 3 to 1), and tobacco use (limited ration of 1.5 to 1)

  • Prohibits discrimination based on health status or condition, or claims, allowing for premium variances up to 30% for employee participation in certain health promotion and disease prevention programs

  • Prohibits discrimination against providers acting within the scope of licensure and applicable state laws

  • Requires all insurers to include defined essential benefits for all plans and to comply with limitations on allowable cost sharing

  • Prohibits waiting periods that exceed 90 days

  • Allows individuals enrolled in employer form of coverage to maintain their coverage as it was the day it was enacted (grandfathered plans)

  • Rating reforms must be applied uniformly to all plans in a state

  • Require plans to be certified by the Exchange and provide the essential benefits package and to have at least one plan at the gold or silver level

  • Require levels of coverage based on what plan pays: (“metal plans”) Bronze-60% Silver-70% Gold-80% Platinum-90%

  • All Subtitle provisions effective 1/1/2014

Additional Special Rules Added:

  • Voluntary choice of coverage for abortion

  • Abortion coverage cannot be mandated

  • Individual plans determine cover:

  1. No abortion

  2. Only those under Hyde (rape, incest, life endangerment)

  3. Abortions beyond Hyde

  • No Federal Funds for abortion in Community Health Plans beyond Hyde, States may require additional benefits but will assume cost

  • Abortions under Hyde covered in Community Health Insurance options same extent as Medicaid

  • State Community Plans that offer abortion coverage must segregate premiums of cost sharing dollars for coverage for abortion services

  • Cannot consider cost reductions for prenatal care prior to abortion

  • No provider can be discriminated for being for or against abortion if doing so is contrary to religious or moral beliefs

Other Changes in Recent Years

  • Exchanges required to be self-sustaining, allowing charging assessments or user fees (usually passed on to employers)

  • Small group definition changed from 1-50 to 1-100. Large group 100+

  • Requires offering only qualified health plans through the exchange to Members of Congress and their staff. Allows agents or brokers to assist them in applying for tax credits and cost sharing reductions

The basic provisions of the ACA seem reasonable and fairly straight forward but by the time Congress was done with the Bill it was thousands of pages and very complex. The absolute opposition by the Republican Party played a major role in the complexity of the legislation. This was in no small part due to the special interest groups and their lobbying efforts to change the outcome of the ACA. In 2009 an unprecedented amount of $273 million dollars was spent by healthcare lobbyists while the ACA was being debated in Congress. According to the Center for Responsive Politics from the Senate Office of Public Records in 2016, $3.12 billion was spent on lobbying by 11,143 lobbyists. Insurance companies spent $146,662,996. The Healthcare Industry spent $509,584,091 with Pharma and Healthcare products spending $244,095,383 of that. Pfizer alone spent $10million. Industry PAC’s gave $4.4 million to Republican House Races and $2.1 to Democratic House Races. As you can see, Healthcare is big business (1/5 of the GDP) and the stakes are high for those stakeholders.

But this is just the beginning of this very complex conversation. Stay tuned there is more on the ACA impact on Small Business, Funding of the ACA, the primary provisions of the AHCA and Freedom Caucus demands, media myths dispelled by Congressional Budget Office Cost Estimates, etc. (This is the first piece in a multi-post series on healthcare)

Featured Posts
Recent Posts
Search By Tags
No tags yet.
Follow Us
  • Facebook Basic Square
  • Twitter Basic Square
  • Google+ Basic Square
bottom of page