Health reform questions: Your patients will ask, here are some answers

Patients want to know how, and when, the new law will affect their care.

By — Posted May 31, 2010

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Most major changes from the new health reform law won't take effect for several years, but many patients want to know now how their care will be affected.

While physicians have been fielding numerous questions, they don't always have all the answers.

Here are some of the basic questions doctors might hear from patients -- and some of the details that could prove helpful in answering them.

When do the reforms start?

Most of the major changes in the law won't happen until 2014. That's when the government aims to help cover tens of millions more people through a combination of insurance guarantees, coverage mandates and government subsidies.

Some provisions, however, will kick in before that. Later this year, insurance companies will be prohibited from denying coverage for children because of preexisting conditions or from kicking kids off the insurance rolls if they become sick. Also starting this fall, dependent children will be able to stay on their parents' coverage until age 26. New high-risk insurance pools soon will start covering people who have been uninsured because of their medical conditions.

Between 2011 and 2014, regulators will lay the rest of the groundwork for the main overhaul -- including tightening restrictions on insurers, boosting primary care and enhancing preventive coverage. The federal government and states will take steps to handle a significant number of newly insured people.

Once 2014 rolls around, assuming the law has not been significantly amended or repealed by opponents, the centerpiece reforms will take effect. That's when the overhaul is designed to start really cutting down on the number of people without coverage and making insurance more affordable, accessible and standardized for many.

What will I be required to do?

The largest single change, as far as an individual patient's responsibility is concerned, starts in 2014 when he or she in most cases will be required to obtain a certain level of coverage -- with government help or not -- or else pay a tax penalty for noncompliance.

The penalty will start at $95 or 1% of income for individuals, whichever is higher. That will phase up to $695 or 2.5% of income in 2016 and beyond. Families that opt not to buy coverage will pay a fee of $285 or 1% of income starting in 2014, phasing up to $2,085 or 2.5% of income in 2016 and beyond.

Under special circumstances, a patient might receive a financial hardship or religious objection waiver to the penalty. Young patients in their 20s also will be given the option simply to purchase a catastrophic plan that just covers their medical expenses beyond a certain level of out-of-pocket spending.

Will you keep me as a patient?

Nothing in the reform law requires a physician to continue seeing existing patients or to take on new ones through insurance exchanges, though many say they will as long as their practices can afford to provide the care.

The government hopes to keep doctors working in the system and seeing newly insured patients through several temporary and long-term measures. These include a 10% Medicare primary care and general surgery bonus that will be in place in underserved areas from 2011 through 2015. Primary care doctors seeing Medicaid patients will receive Medicare rates for primary care services that they provide in 2013 and 2014.

But the reform law does not address the overall Medicare physician payment system, which has physicians lined up for several years of deep pay cuts. Many doctors say they will stop seeing new or existing Medicare patients if those cuts take effect or if permanent payment reform is not enacted.

What's this going to cost me?

Patients with higher incomes will be paying for part of the reform law's coverage expansions.

Individuals making more than $200,000 a year and couples earning more than $250,000 will see their Medicare payroll taxes go from 1.45% to 2.35% in 2013, a year before the expansions kick in. Certain interest and stock dividend income also will be taxed at a higher rate for higher-income people, and those who deduct medical expenses from their taxes or contribute to health flexible spending accounts will be more limited in their ability to do so. There also will be limits on what is covered using flex account dollars. For instance, over-the-counter medications no longer will be covered.

The effect of the reforms on patient premiums and on health costs in general is less predictable. Health plans are expected to take on many new paying customers, but they also must offer coverage regardless of medical condition and are not allowed to charge sick patients more. Insurers will be able to increase premiums based on age, but by a ratio of no more than 3-to-1 compared with young enrollees.

Certain high-cost insurance products, sometimes called "Cadillac plans," will be taxed at 40% after exceeding a certain cost for the year, an assessment that might be passed onto enrollees in the form of higher premiums.

As for how much the government will spend, the roughly $1 trillion reform package by at least one estimate actually will reduce the federal deficit by about $150 billion over the next decade, though this figure has been disputed.

Are Medicare or Medicaid going to help more?

Starting this year, with the help of drug companies, Medicare will start closing a gap in its prescription drug plan between the point where initial coverage ceases and when a senior spends enough out of pocket for the catastrophic coverage to kick in. The gap will be closed completely by 2020.

Also starting this year, Medicare will not require beneficiaries to pay anything for certain recommended screenings, such as cholesterol tests and cancer screenings.

Not all coverage will be expanded for seniors. Because the reform law reduces the amount the government will pay Medicare private plans, those enrolled in such coverage might stop receiving certain additional benefits, such as coverage for glasses and hearing aids.

Medicaid also will undergo a major expansion. Starting in 2014, the program will become available to anyone whose income is at 133% of poverty or lower, currently about $14,000 for an individual and $29,000 for a family of four. The federal government will be footing the bill for most of the expansion, but states also will be required to help pay for it, provided a lawsuit by several states challenging the Medicaid piece does not invalidate it.

What's in it for me?

For many patients who don't have coverage and can't afford it, the government in 2014 will offer sliding-scale credits to buy a plan through health insurance exchanges, new marketplaces that will be launched by the reform law.

Those credits, which still will require people to spend a certain percentage of their income on premiums, will not be available to those whose incomes exceed 400% of the poverty level -- currently about $43,000 for an individual and about $88,000 for a family of four. Out-of-pocket spending also will be limited.

For those who can currently afford insurance but can't get a health plan to cover their preexisting conditions, insurers no longer will be able to deny them coverage.

Those who already are covered and wish to stay on their plans will receive help under the reforms as well. Starting in 2014, annual and lifetime limits no longer will be allowed for benefits deemed essential, and new plans will be required to cover certain benefits that they might not have had to cover before.

Employers also are going to be expected to step up to the plate. Starting in 2014, most companies that don't offer insurance to workers or who decide to drop their coverage will need to kick in part of the premiums for employees who sign up for plans through the insurance exchanges.

Will there be enough doctors to see everyone?

The availability of physicians to treat the more than 30 million uninsured people who are expected to gain coverage under health reform is another big wild card.

Most experts predict a major shortage of physicians over the next decade, a situation expected to hit primary care especially hard.

The reform law attempts to shore up primary care and other vulnerable areas through the temporary Medicare and Medicaid bonuses, though some dispute whether they are large enough and will last long enough. The federal government also will commit more money toward primary care training, redistribute unused medical education slots to primary care and general surgery, and commit more funding toward incentives for primary care doctors to work in critical areas.

Innovative care delivery models and measures aimed at boosting health quality and efficiency also are part of the reform law's plan to maximize the power of the existing physician work force.

How might our plan of care change?

Reform architects say the coverage expansions should improve access to preventive care, allowing physicians to order relatively fewer complex services and hospitalize fewer patients. Effective in 2014, insurers will be required to cover a certain set of basic services, meaning that doctors and patients might not need to find as many alternatives to care that otherwise would be deemed too costly.

The reform law aims to encourage alternative models of care, such as patient-centered medical homes and accountable care organizations, that could change the way patients see their care coordinated. Government-sponsored researchers will compare various treatments for the same condition and provide guidelines for physicians on what seems to work the best.

Opponents of the reform law say the massive expansion of health entitlements inevitably will lead to government rationing of health care, something reform champions vehemently dispute.

Some doctors also might find themselves limited in terms of where they can send their patients. Starting later this year, the law prohibits new physician-owned hospitals from participating in Medicare and strictly limits expansions of existing doctor-owned facilities, bowing to concerns that such hospitals cherry-pick healthier patients and create conflicts of interest for physician owners. Advocates of the hospitals say the provision is a poison pill for their industry and will decrease patients' options for specialized, high-quality care.

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Still up in the air

Some major details of the health reform law were not spelled out completely in the legislation. Instead, they will need to be determined through the federal rulemaking process in the coming months and years. The reform concepts that will be finalized through regulation include:

Preexisting condition: Uninsured people with certain medical conditions will be eligible for special coverage this year, but the law doesn't specify exactly who would qualify.

Health care spending: Starting in 2011, insurers will need to spend a certain amount of their enrollees' premiums on patient care, but questions remain as to what that care actually entails.

Benefits summaries: In 2012, health plans will need to start offering standardized summaries of their products that explain benefits in a an understandable way, but plans have not been fully instructed on how to present them.

Qualifying health coverage: Individuals will risk tax penalties if they do not obtain a minimum level of coverage by 2014, but that standard has not been defined.

Essential benefits: By 2014, the federal government will have phased in prohibitions on placing monetary limits on benefits deemed essential, but that list has not been compiled.

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Where to send patients for more information

Although for many patients the first stop for information on the health reform law is the doctor's office, it does not need to be the last. Here are some resources for patients who still have questions.

  • Federal government (link)
  • American Medical Association (link)
  • Kaiser Family Foundation (link)
  • Consumer Reports (link) -- includes insurance plan ratings for paid subscribers only
  • Families USA (link)
  • Medicare Rights Center (link)

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