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DuPage social service providers get primer on Obamacare

Benefits summary

Stipulations contained in the Patient Protection and Affordable Care Act of 2009, set to take effect next year, guarantee a set of 10 essential health benefits. Here is what they include:

Ambulatory patient services

Emergency room services

Hospitalization

Maternity and newborn care

Mental health and substance abuse services

Prescription medications

Rehabilitation

Laboratory services

Preventive and wellness services, including chronic disease management

Pediatric services, including oral and vision care

Updated: February 26, 2013 6:14AM



Navigating the redrawn national health care map will take some presence of mind, and perhaps a compass at first. It also likely will call for patience on behalf of patients.

Representatives from an array of area nonprofits heard details Wednesday morning about implementing the Patient Protection and Affordable Care Act of 2009. Many features of the health care overhaul, a policy centerpiece of President Obama’s first term, are scheduled to take effect in 2014. Assorted provisions, such as coverage of young adults through their parents’ existing plans, are already in place.

Maureen McHugh, executive director of the DuPage County Health Department, said uncertainties lingered as the topic of health care reform was discussed over the past several years. Interest in the effort fluctuated with the coming and going of election cycles, she said, the challenges to the law mounted by more than half of the states’ attorneys general, and the wait for last June’s ruling by the U.S. Supreme Court that upheld key provisions of the act.

“The really good news, regardless of how you feel about the Affordable Care Act, is that the decision has been made,” McHugh said in launching the morning-long summit.

The legislation’s enactment played a significant role, McHugh said, in the partnership announced Tuesday between Edward Hospital & Health Services in Naperville and Elmhurst Memorial Healthcare that will create a three-hospital health care system.

“How did that start? The Affordable Care Act,” she said.

According to John Bouman, an expert on health care for underserved populations, the changes will bring badly needed relief to a broken system.

Accessibility matters

Bouman said arranging health care remains a challenge, even for those who have insurance. A medical emergency can spell disaster for those who lack coverage; prohibitive medical bills, he said, are the leading cause of personal bankruptcy filings in the U.S. And the delivery system is often a dysfunctional patchwork.

“There’s little in place for control, or quality of care, for that matter,” said Bouman, president and advocacy director for the Sargent Shriver National Center on Poverty Law in Chicago.

The new set of regulations will put into insurance plans most of those who now resort to emergency room care because they have no coverage. Bouman said that tab is picked up by those with insurance, each of whom pays out about $1,000 annually for the medical bills of the uninsured.

The new legislation also will guarantee coverage for those with existing health conditions. The requirement was implemented for children in 2010 and takes effect for adults next year. Sliding scales will guide the rates set for premiums, deductibles and co-pays.

“Everybody, at least theoretically, has access to health care at the end of the day,” Bouman said.

Government will have a far higher profile and more responsibilities under the new system, he said, “but it is far, far from a government takeover.”

Medicaid, historically provided for only very young and old people and those with severe disabilities, will also become available next year to young adults, veterans, “empty nesters” and those with medical needs that don’t meet the official definition of disability. For the first three years after the state-administered coverage is extended, Bouman said, federal money will fund the entire cost.

“That’s billions of dollars that comes into a state’s economy,” he said. “This is really an extremely big deal.”

An ounce

The act’s emphasis on preventive services, such as periodic screenings and other wellness support, is expected to reduce the sums individuals and insurers now spend, and medical information technology upgrades will cut the number of duplicated procedures. The reforms also will bring in 36 million of the 50 million Americans who now have no coverage; those excluded will be mostly undocumented immigrants.

Bouman acknowledged the process is complicated, and many decisions will wind up trickling down to states, counties and communities.

“It’s imperfect. It’s Washington sausage-making,” he said, advising the social service specialists to consider it a good thing if the transition generates many new questions. “You may find you’re the one who can provide answers.”

Those who opt not to take out policies for themselves will be fined through a new tax penalty, beginning in 2014. Initially the tax will be $95 annually or 1 percent of the person’s income, whichever is greater, but no more than $285. The penalty will go up in 2016 to $695 or 2.5 percent of income, with a $2,085 cap.

One of those at the summit said that if premiums cost more than the fine, it could be difficult for some people who are currently healthy to justify buying coverage.

Stephanie Altman, program and policy director for the Chicago agency Health and Disability Advocates, said a study done when Massachusetts enacted health care reforms found that those who opted for coverage over the risk of penalty said they dislike paying fines and prefer to obey the law.

“And they want insurance,” she said.

‘Pent-up demand’

Altman said that while specifics have not yet been laid out, the health reform measures will bring “big, big, fundamental changes” to health care. And those in social services will play active roles in ushering in those changes, from identifying and enrolling those who will be newly eligible for Medicaid coverage — some 611,000 people statewide — to guiding consumers through the new systems.

Stephani Becker, a senior analyst on the advocacy agency’s team focusing on the new access provisions, said one of the initial challenges will be processing the sizable backlog of people who have foregone preventive care and treatment for current ailments and health conditions, because they can’t afford care.

“There’s this pent-up demand, so the least healthy and the older individuals are going to be among the new Medicaid-eligible and most likely to enroll,” Becker said.

An array of details still need to be ironed out, such as coverages and costs within the four-tier health insurance marketplace that will be used to help consumers shop for the most suitable coverage.

“A lot of things are just going to be different, for better or worse,” Bouman said, adding that effective management and productive political discourse will help with the transition. “We’re in that moment now where everything could change and be more cooperative.

“We’ll see.”



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