On March 23, 2010, the Affordable Care Act was signed into law by then President Barack Obama. There were benefits and disadvantages to the Act, known as the “ACA”; depending on one’s view and situation. For those who previously paid many hundreds of dollars for limited health care plans, the ACA often reduced costs, increased coverage and enabled those with pre-existing conditions to obtain healthcare. This paper will discuss and analyze some of the ramifications for those in Texas during and after the time when healthcare became digitalized and accessible primarily through the Internet.
Among the most important and highly debated areas of the ACA was the regulation pertaining to pre-existing conditions. While this category may apply to anyone of any age, it is most relevant to persons with ongoing disabilities and/or those who are seniors. As amended in 2010, the regulations PHS Act section 2704 (26 CFR 54.9815-2704T, 29 CFR 2590.715-2704, 45 CFR 147.108) and PHS Act section 2704 (45 CFR 147.108) (in ‘interim final’ form) have respective applications for the general public and “individuals/enrollees who are under 19 years of age” (Department of Health and Human Services, 2010, para. 6-7). These regulations are very complex and include specific limitations on costs allowed per claimant, with variations contingent on whether the policy is through an employer group plan or is an individual policy. Although the listed regulations do not exhibit recent changes, it is expected that with the attempted repeal of the ACA, the area of pre-existing conditions will be one that will be reduced or eliminated.
Very simply, prior to the ACA, healthcare insurance – both for individual and employer-based plans – limited or excluded many diseases, disabilities and conditions that were in effect prior to obtaining the plan. Because Medicaid is income limited, many consumers had to choose between self-paying for needed services and medications, going without, or trying to find free clinics and medications. Some of the most needed medicines were imported from other countries, with mixed results, as some nations do not have the regulatory or monitoring services of the Food and Drugs Administration (FDA).
Ideologically, the notion of everyone receiving the medical care they need is desirable. In reality, medical costs are driven up by those who do not have insurance or a primary care physician. Use of the Emergency Room for well-care and non-urgent issues ultimately costs money to the public and to each state’s Medicaid fund. Among the goals of the ACA were to ensure that each American had a designated physician and that costs for care that formerly were borne by Medicaid for Emergency Rooms (and this includes transport by ambulance, medivac, and other individual carriers) would be reduced with healthcare plans that were comprehensive in general scope. The analyses on these are not complete, and care is changing now.
This entire issue revived discussion and support for single-payer healthcare, as is practiced in many European and Nordic nations. This would create a more equitable distribution of costs and expectations, and those who desired ‘Cadillac care’ could purchase separate plans for additional services or procedures. Culturally, there seems to be a disparity between what Americans say they want and what they are willing to pay for. In theory, many of us have a relative or other loved person whom we want to be able to access whatever healthcare is needed. We say as a nation that we cherish our children, our seniors and our people with disabilities, but in examining the facilities we offer for care, the hourly pay for workers in these fields, and the medical and other services we offer, we seem to fail to understand that words are not services.
Aside from requiring advanced English reading skills, the volume of text in these regulations is forbidding, and the chances that the ‘average consumer’ will fully understand their services and limitations are few. It has been said that laws are designed to elude comprehension, and for many policyholders, this is the case. As a healthcare professional, it will very likely be difficult to explain to patients why certain procedures or medications are not available under their plan, or why they may have limited or no choices in providers, office hours, locations or appointment times. This role seems like one of a monitor or general ‘bad guy’ in the system.
At the time these regulations were posted, the United States was undergoing significant change in the area of healthcare. Medicaid expenses had grown drastically, and because there is a required individual state ‘pay-in’ for Medicaid coverage, many states were considering limiting both costs and categories of care for direct Medicaid recipients and those whose insurance plans were linked to Medicaid costs. During this time, and to this day, there is a significant split between Democratic and Republican views on both Medicaid and the issue of coverage for pre-existing conditions.
A national article from last year highlights the importance of pre-existing conditions in legislative considerations and votes about healthcare. While noting the predominantly Democratic support for this provision, the article also notes that some Republican leaders have been loath to make drastic changes or cuts to this area. In these authors’ view, “Republicans supportive of the health care overhaul have defended its handling of pre-existing conditions in a range of ways” (Burns & Goodnough, 2017, para. 31). The whole issue has become even more of a hot button when the subject of possible “Death Panels” (in theory, groups or entities that would select who lives or dies) became the fodder for both legislative debates and social media. Many celebrities and legislators – aside from those in the public who voiced their concerns – have family members and friends whose lives depend on care for ongoing disabilities and conditions.
Among the supports that are available to individual states are Medicaid Waiver programs. These ‘grants’ enable the states to supplement services to specific populations (children, those with economic urgency, people with disabilities of all ages) in programs that have their own regulations and rules. The currently posted Medicaid Waiver information for Texas lists the eligibility information, availability, locations, and other information. It notes that those on the waiting list, or “Interest List” for different Waiver programs number “151,161”, and that “Supported Living (attendant care for those living independently or in clustered living) is available only in Houston” (Nangle, n.d., para. 9). This website also notes that income restrictions apply to eligibility. There are specific services that are available only to individuals with identified disabilities within certain categories.
Approximately eighteen months after the implementation of the ACA, a public policy analysis organization reviewed the overall impact/success of the Medicaid Waiver programs, with notes regarding individual state issues. At the time of publication, there was not an ability to judge whether “premium assistance” through Medicaid was beneficial overall, but the report notes that “only 12 out of 38 premium assistance programs were more cost-effective than direct Medicaid” (Ma, 2015, para. 7). Areas of concern to this organization were “Premium assistance’s impact on enrollment, private market fluctuations (two insurance providers are required for each state), cost of monthly (individual) contributions to healthcare/Healthcare savings accounts, lockouts for failure to pay/late payments, and limits or reductions in non-emergency medical transportation” (Ma, 2015, para. 4). While this policy review does not highlight or focus on Texas, the previously referenced document does note limitations that can create issues for Texans and those providing services.
Before discussing more specific issues in Texas regarding pre-existing conditions, there is a related issue that is perhaps more pressing in Texas than in some other states. This is the matter of access, both in regard to enrollment and a healthcare plan; and in regard to actually obtaining services, whether these be emergency care, well-care appointments, specialty services such as OT/PT, lab work or other available options under the ACA or a Medicaid Waiver program.
Initial problems were caused by the requirement to enroll online at Healthcare.gov. In addition to the fact that some and perhaps many seniors and people with disabilities do not have computers or technology skills, there are rural and other areas in Texas that do not have affordable Internet services. While Healthcare.gov has a phone number and did/does accept calls, the waiting period was sometimes twenty or more minutes. For those using cell phones, this is sometimes not possible. For those who relied on others to assist them with enrolling, there was and is a potential loss of privacy in regard to the many questions required for the enrollment form. Separately, the system designed to enable consumers to enroll ‘seamlessly’ could not handle the volume of enrollees, and many could not gain access, others were timed-out midway through a session, and others found that the online form was not working or not clear.
Since the initial enrollment period and the recognition of many access issues, healthcare.gov has established five ways for consumers to enroll. These are “online, with in-person help, through an agent/broker, or by mail” (USA.gov, n.d., para. 3-8). Texas is still evaluating its costs and options, and most recently, the state has published a report titled Texas Medicaid Reform Model: A Market-Driven, Patient-Centered Approach. Published in 2015, this report focuses on the mounting costs of Medicaid-based care. It is primarily for legislators and policy analysts.
Separately, a journal study evaluates the status of ‘telehealth’ services in Texas – an option for seniors and those with disabilities and conditions who cannot easily travel. While this might seem like a viable option that could also reduce costs, the authors found that the program declined because of “Lack of significant impact on patient outcomes, in addition to financial, technical, management, and communication-related challenges”; and they believe that such a program could work (summarized) if it “attains patient-centered outcomes, improves cost-effectiveness of managing chronic diseases, improves quality of communication among patients and clinicians, is user-friendly for older adults” (Radhakrishnan, Xie & Jacelon, 2015, para. 3-4). The reduction in services for this program, difficulties in transportation and other access, and recent changes in policy and coverage do not spell good things for Texans.
A recent article in the Texas Tribune notes that the enrollment period for healthcare.gov has been shortened, there are new restrictions, and this “may mean more uninsured Texans” (Allbright, 2017, para. 2). This information is somewhat frightening as if Medicaid is being limited, consumers do not/cannot enroll in the ACA – is it possible that Texans are supposed to go without healthcare until the next enrollment period? It has not yet been fully determined what exclusions and limits will be placed on those with pre-existing conditions. As a future professional in the field, it may come down to whether it is ethical and viable to practice in the state of Texas and also maintain professional standards for care and compassion. Hopefully, there will be changes within the foreseeable future that will benefit all Texans and their health options.
Allbright, C. (2017, December 11). More Texans may be left without health insurance after the end of open enrollment. Texas Tribune [Austin]. Retrieved from https://www.texastribune.org/2017/12/11/open-enrollments-upcoming-end-may-mean-more-texans-without-health-insu/
Burns, A., & Goodnough, A. (2017, May 5). Measure on pre-existing conditions energizes opposition to health bill. New York Times. Retrieved from https://www.nytimes.com/2017/05/05/us/politics/republican-health-care-bill-pre-existing-conditions.html
Department of Health and Human Services. (2010). Regulations.gov (HHS-OS-2010-0014-0001). Retrieved from https://www.regulations.gov/document?D=HHS-OS-2010-0014-0001
Ma, A. (2015). How common Medicaid waiver provisions impact people and state budgets. Retrieved from https://www.communitycatalyst.org/resources/publications/document/Medicaid-Waiver-Provisions-Impact-People-and-State-Budgets-FINAL.pdf
Nangle, A. (n.d.). Texas Medicaid waiver. Retrieved from http://medicaidwaiver.org/state/texas.html
Radhakrishnan, K., Xie, B., & Jacelon, C. S. (2015). Unsustainable home telehealth: A Texas qualitative study. The Gerontologist, 56(5), 830-840. doi:10.1093/geront/gnv050
USA.gov. (n.d.). Apply for health insurance. Retrieved from https://www.healthcare.gov/apply-and-enroll/how-to-apply/