On July 9th the Fifth Circuit Court heard arguments in the appeal of Texas v. Azar, the December case from Ft. Worth that held the insurance mandate in the Affordable Care Act [“Obamacare”]- and more importantly, the entire law- unconstitutional. [For more on the lower court case, see Fontenotes No. 74 and No. 69]
Two of the three judges hearing the case “appeared to be receptive” to the arguments that struck down the law in the district court, but it will probably be months before we have the Appellate Court decision.
Regardless of that outcome, the losing side will likely appeal to the United States Supreme Court- which could very well mean a definitive answer on the future of Obamacare in June 2020, just as the Presidential election hits fever pitch.
Future Fontenotes will address the case as it progresses- and the implications of those court decisions.
For now- let’s take a deeper look at the Affordable Care Act. What does“all of” Obamacare entail? Many things- but here are 25 lesser-known components of the ACA that would disappear with the law.
The Affordable Care Act: Parts We All Know About
There are some components of the ACA that are familiar to us all. These will be negated if the law does not survive:
1. Protections requiring insurance availability (without gouging) for people with preexisting conditions (for more on these protections, see Fontenotes No. 8 – and on a more personal note- No. 67)
2. Sliding-scale Subsidies assisting people in purchasing insurance on the Obamacare Exchanges (also called “Marketplaces”);
3. Medicaid Expansion in 36 States plus D.C. (although some details vary and in 3 states ballot initiatives passed but Expansion has not happened yet.) At least 12.6 million people would lose insurance coverage if the ACA is nullified- 4 in 10 of those people would be children; (for more on the pros and cons of Medicaid expansion see Fontenotes No. 14)
4. The ability to keep children on their parent’s insurance policies until they are 26
These parts of the law are the most popular- and the possibility of losing them has politicians nervous. Republicans on the Hill are taking notice, particularly the threat against pre-existing conditions protections:
“Senate Republicans are reversing course (from saying they don’t want to attempt legislation this year and are now) taking a hard look at health care legislation to replace the 2010 Affordable Care Act in case the courts strike down former President Obama’s signature achievement.” [quote]
What Could We Lose We Don’t Know About?
The Affordable Care Act is famously long. It is long because it is extraordinarily detailed, and touches on every aspect of the American Health Care Delivery System.
What else would be nullified if the Plaintiffs in Texas v. Azar ultimately win? What else is in “All” of Obamacare?
The list is exceedingly long, but here are 25 components of the ACA that are in jeopardy:
Insurance Protections
1. No lifetime Caps within private insurance policies- these caps allow companies to deny further coverage if your needs exceed a certain amount (usually a million dollars) regardless of your good history of paying your monthly premium (I addressed this in Fontenotes No. 32);
2. The Medical Loss Ratio (also known as the 80/20 Rule) which requires Insurance Companies to invest at least 80% of the money they receive in premiums back into the health of their covered population (For more- I wrote about this in Fontenotes No. 9);
3. Limits on the total out-of-pocket expenditures a person (or family) can have in a year (For more on the costs of health care see Fontenotes No. 41);
4. Coverage (at no out-of-pocket expense to you) for preventive screening ordered by your providers, such as mammograms, colonoscopies, and blood work) (For more see Fontenotes No. 7);
5. Provisions allowing insurance companies to offer policies across state lines and developing “regional compacts” with state control/option to opt-out (this was part of Donald Trump’s platform as a candidate– see Fontenotes No. 19);
Building a Better Healthcare Workforce and Supporting Advances in Medicine
6. Student loans for doctors, mental health personnel, nurses, pediatric mental health professionals, dentists, dental hygienists, public health students and allied health (O.T., P.T., etc.) – with a focus on primary care;
7. Increasing financial support for hospitals, especially rural hospitals and those meeting the needs of underserved populations (such as in the heart our cities);
8. Training for personal home health aides, standardization of that training, and a nursing aide registry to monitor those who are good (and more importantly) those who are not;
9. Increased transparency under “The Sunshine Act” that requires public disclosure of money being given by pharmaceutical and DME companies to physicians and teaching hospitals (For more- I wrote about this in Fontenotes No. 5);
10. Tax breaks for investments in therapeutic discoveries;
11. Financial support for innovative medical therapies, including biologics and biosimilars, and more affordable drugs, especially for the poor and their children;
12. Support for “Medical Homes,” requiring a team approach to a patient’s health care and coordination around the patient, rather than the patient having to act as the messenger between all their physicians and providers (see Fontenotes No. 29);
13. Financial support for nursing students, nursing faculty support, and advance practice education for nurses- all intended to increase the number of nurses available in both hospitals and community settings;
14. Funding and development of demonstration projects focused on health promotion, wellness, and disease prevention;
Nursing Homes, Care for the Infirm & Elderly:
15. More transparency for Nursing Homes, including ownership, compliance, ethics policies, quality monitoring, and consistent enforcement of safety regulations;
16. Funding for projects aimed to increase independence at home for elderly (“Aging in Place”);
17. Closing “the donut hole”- an aberration of Medicare Part D that opens Medicare beneficiaries to exposure for drug costs in the middle of a scale between entry-level and more catastrophic expenses;
18. Providing reimbursement to your physician so they can spend more time with you to discuss how you want to deal with a terminal disease and end-of-life decisions (see Fontenotes No. 24);
19. Adult protective services and “Elder Justice” with enhanced penalties and requirements for reporting injuries in long-term care, and protection of employees who report elderly abuse at nursing homes and skilled nursing facilities,
Assistance to Families & Communities
20. Maternal/child home visitation grants- to bring better post-partum care to new mothers and babies in their homes, as is common in many other industrialized countries;
21. Medicaid for former foster care children to help them with the transition when they “age-out” of Child Protective Services when they are 18;
22. Allowances and calculations to coordinate federal assistance with Medicaid to provide disaster relief for states recovering from a major calamity for up to 7 years;
23. Outreach to notify people who may not be aware of their rights/availability of Medicaid, as well as subsidies to purchase insurance on the Exchanges;
And Two of My Favorites (Maybe Yours Too?)
24. Posting calorie counts on items you order from chain restaurants and fast-food counters (see Fontenotes No. 16);
25. Enhanced funding, stricter rules, and increased penalties for people who fraudulently make millions of dollars while pretending to deliver care– i.e., going after the people who are stealing our tax dollars!
What’s Missing?
Ironically, the thing the public most wants to go away isn’t on this list: High-Deductible insurance policies.
That is because High-Deductible plans were neither created nor mandated by Obamacare.
High-Deductible plans were promoted by the insurance industry long before the ACA- particularly for employers seeking coverage for their employees in the 1990s.
Obamacare didn’t create high-deductible plans- it created an excuse for the insurance industry to bring them back. (for more see Fontenotes No. 22)
More to the point- if the courts eradicate the entire ACA, high deductible plans will continue.
In Closing
This list of 25 items at risk because of the court case against the Affordable Care Act is the result of a casual flipping through my copy of the ACA. They are by no means the most prominent- or significant- parts of the law. This list is only the tip of the iceberg called Obamacare.
Even so, I hope reading about them will give you food for thought as we watch the progress of the Texas v. Azar opinion over the next year.
Want to Know More?
- If you have not read all of the Affordable Care Act- and are now interested in doing so- you can get your very own copy by clicking here. Happy Reading!
- Do you find the Court system confusing? Would you like to know more about the three levels and how the appellate process works? This is a nice guide from “How Stuff Works”: How the Judicial System Works.