Diabetes Forecast

Health Care Reform

What to expect from the new law

By Katie Bunker ,

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. Here's an overview of the law's initiatives that most pertain to people with diabetes.

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.

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.


If you have any kind of Health Insurance

Children with preexisting conditions must be covered.
Insurers are banned from denying coverage to kids under 19 previously diagnosed with diseases and conditions, including diabetes (Sept. 23).

You can't lose coverage simply because you get sick.
Insurers are banned from dropping enrollees when they are diagnosed with a new condition or illness (Sept. 23).

There's no lifetime limit on your policy's benefits (Sept. 23).

Some preventive care is covered at no cost.
Private insurers must guarantee coverage, without requiring co-pays or deductibles, of certain preventive screenings and immunizations (Sept. 23). Medicare and Medicaid will include some free preventive coverage as of Jan. 1, 2011.

Premiums are regulated.
A process is established for reviewing premium increases (plan year 2010). States will later make recommendations for excluding insurance plans with unjustified premium hikes from the American Health Benefit Exchanges.

Adult children can stay on their parents' insurance.
Insurers must cover adult children up to age 26 (Sept. 23, unless the parent is on an employer's self-insured plan and the child is able to get insurance through an employer, in which case 2014).

Early retirees can keep their coverage.
Employers or insurers that provide coverage to retirees ages 55 through 64 receive some reimbursement, to be used to lower costs for enrollees in the employer plan (until Jan. 1, 2014).

If you have Medicare

Those in the "doughnut hole" receive a rebate.
Seniors who fall into the gap in Medicare Part D prescription drug coverage in 2010 get a one-time $250 refund.

If you are Uninsured

You can buy coverage even if you have a preexisting condition (like diabetes).
People with preexisting conditions who have been uninsured for at least six months may apply to purchase coverage through high-risk pools until the health insurance exchanges program begins in 2014.

Health Initiatives

Breast-feeding support. Employers with more than 50 employees must provide break time and a private place other than a bathroom for women who need to pump breast milk at work. (Nursing is associated with reduced diabetes risk in both mothers and their breast-fed children.)
Community health. Funding for community health centers and the National Health Service Corps is increased by $11 billion over five years (Oct. 1).
Generic biologics. The Food and Drug Administration is allowed to approve generic versions of biologic drugs after 12 years of brand exclusivity; applies to the diabetes drugs Symlin, Byetta, and Victoza, but not to insulin, which is covered under separate law.
Long-term care. Extra federal dollars go to states that encourage home care in lieu of nursing homes for those on Medicaid. Spouses can keep more assets when care is delivered at home (Oct. 1).
Native American health. The Indian Health Care and Improvement Act is reauthorized and expanded. (Native Americans have among the highest rates of type 2 diabetes in the world.)
Prevention. Prevention and wellness programs are expanded, including establishing a $15 billion Prevention and Wellness Trust fund. A new National Diabetes Prevention Program is established to provide grants to community groups for lifestyle interventions proven to reduce the risk for type 2.
Research. The Cures Acceleration Network, part of the National Institutes of Health, is established to award grants for research into cures for diseases like diabetes.
School-based care. New programs support school health centers, which provide basic medical care and mental health counseling to students in areas that lack such services (Oct. 1, 2010, through Sept. 30, 2014).


If you have any kind of Health Insurance

You may get rebates from your insurer.
New private health plans must report the proportion of premium dollars spent on medical care, and provide rebates to consumers where applicable (Jan. 1, 2011).

Rules change for health savings and flexible spending accounts.
Reimbursement for drugs bought over the counter is no longer allowed in health savings accounts and other employer-sponsored medical savings arrangements (Jan. 1, 2011). Flexible-spending contributions are limited to $2,500 per year (Jan. 1, 2013).

If you have Medicare

Those in the doughnut hole are further compensated.
The Medicare Part D prescription coverage gap gets smaller, and Medicare beneficiaries caught in the doughnut hole get a 50 percent discount on brand-name drugs, including insulin, and begin to get subsidies to pay for generic drugs (2011; by 2020, the doughnut hole should be closed).

Higher-income Medicare recipients get less of a subsidy.
Part D recipients with incomes over $85,000 for an individual or $170,000 for a couple receive less government help in paying their premiums (Jan. 1, 2011).

More prevention is covered.
Under traditional Part B, you can get an annual physical and some preventive services free of charge, along with incentives to complete behavior modification programs. Medicare beneficiaries also receive a free annual visit for developing a personalized prevention plan (Jan. 1, 2011).

Payments to the Medicare Advantage program are reduced.
Medicare begins reducing how much the government pays to Medicare Advantage, privately run health plans that provide Medicare-approved coverage in which plans are compensated at a higher rate on average than through regular Medicare (Jan. 1, 2010).

You may be able to receive certain kinds of medical care at home.
A demonstration program offers home care to high-need Medicare beneficiaries; cost savings from reduced hospitalizations, improved health outcomes, etc., are shared with participating health providers (Jan. 1, 2012).

If you have Medicaid

Primary care doctors get more money for treating Medicaid patients.
Federal funding reimburses primary care doctors at the same level as for Medicare patients (2013-2014).

States get incentives for providing free preventive care under Medicaid (Jan. 1, 2013).

Health Initiatives

Long-term care. You can choose to pay monthly premiums through payroll deductions (at participating employers) to buy insurance to help you stay in your home if you become disabled (Jan. 1, 2011).
Menu labeling. Chain restaurants must display calorie information and make other nutrition information available upon request (regulations due by March 23, 2011).

2014 and Beyond

If you have any kind of Health Insurance

Coverage cannot be dependent on health status or sex.
All insurers are prohibited from denying coverage or charging higher rates on the basis of preexisting conditions or sex. Insurers may consider age, geographic area, family composition, and tobacco use in setting premiums, but they may not charge older adults more than three times what younger people pay (2014).

There's no annual limit on your policy's benefits (Jan. 1, 2014).

You are guaranteed a minimum level of benefits.
Health plans must provide a certain level of preventive care and chronic disease management. Does not apply to grandfathered plans and large-employer self-insured plans (Jan. 1, 2014).

If you switch insurers, your coverage must start within three months.
All plans must eliminate coverage waiting periods greater than 90 days (2014).

You can get insurance through the exchanges.
Starting this year, if you are not covered through your employer or if your employer's insurance plan fails to meet certain criteria, you can shop the exchanges for health coverage. Small businesses (fewer than 100 employees) can also use the exchanges. You may choose to keep your individual plan outside the exchanges if your insurer still offers it (2014).

Depending on your income, your premiums may be subsidized.
Individuals and families with incomes between 133 percent and 400 percent of the federal poverty level get tax credits to help them buy insurance through the exchanges (2014).

Out-of-pocket costs are capped.
In the small-group market (plans for small businesses and other groups), deductibles are limited to $2,000 for individuals or $4,000 for families. For people in plans that are not grandfathered or self-insured large-employer groups, out-of-pocket costs for essential benefits packages are limited to $5,950 per year for individuals and $11,900 for families (Jan. 1, 2014).

If you have Medicare

The doughnut hole closes further.
The upper limit of the gap in Medicare Part D prescription coverage is lowered (2014–2019), and those in the doughnut hole get discounts on prescription and generic drugs phased in over 10 years (the gap is expected to close in 2020).

If you have Low or Moderate Income

You may qualify for Medicaid or for tax credits to purchase coverage in the exchanges.
Under Medicaid expansion, people with incomes of up to 133 percent of the federal poverty level are covered by Medicaid, and adults no longer have to be disabled or have children in order to qualify. States can opt to expand Medicaid eligibility sooner. Americans who fall between 133 percent and 400 percent of the federal poverty level get tax credits to help them buy insurance in the exchanges (2014).

The Children's Health Insurance Program (CHIP) grows.
CHIP funding is extended through 2015. States must maintain current income eligibility levels for children in Medicaid and CHIP until 2019 and offer tax credits in the exchanges for the families of CHIP-eligible children who can't get in the program because of enrollment caps (2014).

If you are Uninsured

You may be penalized.
Almost all Americans are now required to have health insurance, or face an initial penalty in 2014 of $95 or 1 percent of income, whichever is greater. The penalty rises to $695 or 2.5 percent of income in 2016. Large companies are fined if they fail to offer employees coverage (2014).

Health Initiatives

Statistics and education. A new Diabetes Report Card tracks health outcomes at the state and national levels; death certificates include more information about diabetes-related mortality in order to give a more realistic picture of the toll of diabetes on the nation; new federal recommendations delineate how much diabetes medical education should be required for medical licensing and board certification.

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.



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