Clinical Geriatrics

At long last, the United States has agreed to a plan for “comprehensive” healthcare coverage…or has it? While there are still those who lobby for or against the approved changes, many are still unsure of what to expect with the new legislation. The following is an attempt to summarize some of the major provisions in the legislation that was passed on March 21, 2010, with a House vote of 219-212 to pass the Senate-passed reform bill, the Patient Protection and Affordable Care Act (H.R. 3590). The Reconciliation Act of 2010 (H.R. 4872) was later voted upon and approved 220-211 to reflect changes sought by the House. These Bills extend healthcare coverage to 32 million Americans representing 95% of legal residents and 92% of all U.S. residents at a cost of $940 billion over 10 years.

It will expand coverage to 32 million persons by 2019 by expanding public programs and offering private sector health insurance reform. Beginning January 1, 2014, all U.S. citizens and legal residents will have to obtain coverage or face a tax penalty. Individuals with employer-based coverage will be able to retain this same coverage. Those without employer plans will be able to obtain coverage through newly formed “health insurance exchanges.” Subsidies will be made available to assist low-income individuals in purchasing these policies; Medicaid will be expanded to provide coverage for those living below a certain economic level. While employers are not required to provide coverage, large employers will be charged a “free rider” assessment if their employees purchase healthcare coverage through the exchange program with federal premium subsidies. Beginning in 2014, all state Medicaid programs must cover individuals who are below 133% of the federal poverty level. States will be given federal funds to pay for the newly expanded population requiring coverage, starting with 100% federal financing for 2014-2017. This will be reduced to 90% starting in 2020 and thereafter. States that already cover this population will be given additional federal assistance.

Beginning in 2011, states must establish health insurance exchanges through which individuals and small businesses can purchase qualified private health insurance coverage. Coverage similar to that provided through the Federal Employee Health Benefit plan will be offered through the exchanges, with oversight by the U.S. Office of Personnel Management. Consumer Operated and Oriented Plans (Co-Ops) will be created as well to foster nonprofit, member-run health insurance cooperatives. No government-run program will be established.

Within 90 days of enactment, this Bill offers temporary mechanisms to provide coverage to individuals with pre-existing conditions and for non–Medicare-eligible retirees over age 55. Within six months of enactment, it will prohibit insurers from setting annual and lifetime limits, from dropping coverage unless clear fraud has been demonstrated, and from excluding coverage to children based on a pre-existing condition. Parents also will be able to include dependent children up to the age of 26 on their own health insurance. Beginning in 2014, health insurers will be prohibited from excluding coverage based on pre-existing conditions for adults, will have limits imposed on premium ratings, and must guarantee insurance coverage for anyone seeking it.

Beginning in 2013, hospitals will have a financial penalty for “excess” readmissions when compared to “expected” levels of readmissions, based on the 30-day readmission measures for heart attack, heart failure, and pneumonia that are currently part of the Medicare pay-for-reporting program. Critical access hospitals and post-acute care providers will be exempt from this. Beginning in 2012, hospitals and physicians can establish voluntary Accountable Care Organizations (ACOs).