How will the newly enacted Patient Protection and Affordable Care Act change the way that you get health care coverage? The bill that President Barack Obama signed on March 23 seeks among other things to fix the problems that many people with diabetes have in securing quality care. The law is certainly complex, but given how essential quality health insurance is when you have diabetes, it’s important to know what is changing, and when (timeline begins on next page). Here’s an overview of the law’s initiatives that most pertain to people with diabetes.
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A prime example of a problem with the current system is the concept of “preexisting conditions.” Many people with diabetes get their health insurance through their or their spouse’s (or parent’s) employer. Others try to buy it on their own. But since many health insurance plans impose restrictions if you already have diabetes (a preexisting condition), switching jobs or getting laid off could mean losing health coverage. Beginning this year, insurers can no longer deny coverage to children because of preexisting conditions; starting in 2014, the same will be true of adults, too (until then, high-risk insurance pools will offer coverage to people who can’t get insurance otherwise).
Today, if you have diabetes and don’t have Medicare, Medicaid, or an employer-provided plan, buying your own insurance can be either financially prohibitive or pretty much impossible. Under the new law, coverage will be as available to people with diabetes as it is to everyone else, through the new American Health Benefit Exchanges that begin operating in 2014. These marketplaces will allow people (and businesses with fewer than 100 employees) to purchase insurance from both private insurers and nonprofit groups. “It’s likely that people purchasing coverage on their own will eventually move to the exchanges,” says Jennifer Tolbert of the nonpartisan Kaiser Family Foundation. Health plans in the exchanges must offer a minimum set of benefits, and states may drop plans that make unjustified premium increases.
One of the goals of health care reform is to prevent both chronic diseases and their complications. “We had a system in which insurance companies would pay for an amputation caused by diabetes, but all too often would not pay for the care that would have prevented an amputation in the first place,” says George Huntley, former chair of the board of the American Diabetes Association.
Before the new law, insurance companies could drop people when they were diagnosed with a condition like diabetes, or its complications. Another provision going into effect in 2010 prohibits that practice. Plans will also be required to cover policyholders’ adult children up to age 26. Lifetime and annual limits on policy benefits will eventually be banned. Seniors with Medicare Part D will see the “doughnut hole” gap in prescription drug coverage gradually disappear.
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The law also recognizes the nationwide impact of diabetes. For example, the Cures Acceleration Network, which will start receiving funding this year, will finance research into cures for diseases. A new National Diabetes Prevention Program will fund grants for community-level efforts to help people lower their risk for type 2. Additional initiatives boost the number of health care workers and increase the availability of medical services in areas hardest hit by diabetes and other chronic diseases. Other provisions—like requiring restaurant chains to post calorie counts on menus—attempt to create a healthier environment in order to stem the exponential growth of type 2 diabetes nationwide.
The law expands the ability of employers to use workplace wellness programs to reward employees based on certain health measures. The intent is to encourage people to engage in activities that both improve their health and reduce the cost of care. However, diabetes advocates are working to ensure that employers won’t use the provision to keep people with diabetes from getting affordable coverage because, say, their blood glucose exceeds a certain level.
Throughout the legislative process, the American Diabetes Association worked with members of Congress to represent the interests of people with diabetes. “We heard from so many people who couldn’t get insurance or had their claims denied because of their diabetes,” says Huntley. “Eliminating preexisting condition exclusions and establishing the high-risk pools lessened the fear of losing coverage, or having such financial strain that people have to cut back on essential medications like insulin.”
How some components of the law will play out remains to be seen. “The final bill was not perfect by anyone’s estimation,” says Huntley, “but it was a major step forward for access to care for people with diabetes.” When it comes to diabetes, good, affordable health care will remain a priority long after the words health care reform have left the headlines.
Glossary of Terms
|Children’s Health Insurance Program (CHIP): insures children and teens whose families can’t afford health insurance but make too much to qualify for Medicaid.||Co-pay: a payment that an insured person must make for a medical service, such as a doctor’s visit or prescription medicine (for example, $20 per office visit, or $5 per prescription). The amount is set by the insurance policy and varies by type of service.||Deductible: the amount that must be paid out of pocket for health care expenses in a given year before an insurer starts paying for medical claims under a policy. Not all health plans have a deductible.|
|Doughnut hole: in Medicare Part D prescription drug coverage, a gap between the initial coverage limit and the minimum threshold for catastrophic coverage. A Medicare beneficiary who has spent enough on prescription drugs to exceed the coverage limit in a given year falls into the doughnut hole and is responsible for the total cost of all prescriptions filled until spending enough to qualify for catastrophic coverage.||Exchanges: state-level marketplaces through which individuals, families, and small businesses will be able to purchase insurance. The exchanges are intended to help small businesses and people without employer coverage compare plans and band together to get better prices.||Grandfathered plans: Health insurance plans that existed prior to health care reform being signed into law on March 23. Grandfathered plans do not have to comply with some provisions of the new law. However, these plans maintain their grandfathered status only if certain elements of coverage do not change.|
|Preexisting condition: a medical condition that was diagnosed before beginning coverage with a new health plan. Currently, many insurers deny coverage based on such conditions, and large plans may impose a waiting period before coverage begins.||Premium: the amount of money a person, family, or business pays for insurance coverage.||Subsidy: monetary assistance from the government to help pay for insurance premiums, often to people with low incomes.|