Dennis Potvin - Tennessee Democrat

The Pros & Cons of Affordable Care

Medical care From the 1970s to the 1990s, the fastest-growing for-profit industry in America was privatized hospitals, outpacing even the computer and technology industries. Yet in the early 90s, over 30 million Americans lived without any sort of health insurance coverage. This meant that the economic expansion of the medical industry did not equate with the expansion of coverage for Americans. It simply meant that the industry was finding better ways to be profitable for its stockholders. A big part of this was by denying coverage.

The growth of technology allowed easier methods for health providers to deny coverage for potential consumers by detecting adverse medical conditions at the application stage. And in the early 90s, they had it down to a science. This was not only for private insurance carriers; this included employer-provided coverage. It meant that, in the early 1990s, an employee’s immediate family members could be denied coverage for having specific diseases and pre-existing conditions. It also meant that employers could set lifetime coverage limits on employees. HIPAA, signed into law in 1996, changed all that.

The Health Insurance Portability and Accountability Act (HIPAA) accomplished many important tasks in relation to employer-provided benefits that continue to this day. It protects coverage for individuals who lose or change jobs, and prohibits group health plans from denying coverage to individuals with certain diseases and pre-existing conditions. It also prevents plans from setting lifetime coverage limits.

However, from 1996 to 2010, private insurance companies (providing coverage not linked to employment) continued to pick and choose which consumers would receive coverage. From 2007 to 2009, the four biggest for-profit health insurers – Aetna, Humana, UnitedHealth Group and WellPoint (now Anthem) – denied coverage to more than 651,000 people over the three-year period. Congressional investigators discovered that 1 out of every 7 consumers with pre-existing conditions was denied coverage.

The Patient Protection and Affordable Care Act (ACA) was signed into law in 2010 as a way to broaden coverage and expand the best tenants of HIPAA into private coverage. The ACA required that Americans obtain medical insurance coverage or face a fine, but also paved the way for those who were previously denied coverage to obtain it. The ACA required that:

In the years since the inception of the ACA (nicknamed “Obamacare”), both Pro’s and Con’s have been identified.

Pros of Affordable Care Act

Medical Care
MORE AMERICANS HAVE HEALTH INSURANCE IN THE ACA ERA
More than 16 million Americans obtained health insurance in the first five years of the ACA, with a large percentage being newly insured young people. In addition, children may now remain on their parents’ benefits until the age of 26.
HEALTH INSURANCE COMPANIES ARE MORE ACCOUNTABLE
Insurance companies are now required to spend at least 80% of insurance premiums on medical care and improvements.
PEOPLE WITH PRE-EXISTING HEALTH CONDITIONS CAN NO LONGER BE DENIED COVERAGE
A pre-existing condition, such as cancer, made it difficult for many people to get health insurance before the ACA. Most insurance companies wouldn’t cover treatment for these conditions.
NO LIMITS ON CARE FOR TIME OR FOR COST
People with chronic health problems once ran out of coverage or ran out of time. Companies can no longer maintain a pre-set dollar limit on coverage.
PREVENTATIVE SCREENINGS ARE FULLY COVERED
Proactive health care can avoid or delay major health problems later, so annual checkups are now fully covered, or have low co-pays or deductibles.
LOWER PRESCRIPTION DRUG COSTS
The ACA aims to limit out-of-control pharmaceutical costs. Savings on prescription drugs exceeded $15 billion with the first five years of the ACA.

Cons of the Affordable Care Act

HIGHER PREMIUMS, DEDUCTIBLES AND OUT-OF-POCKET MAXIMUMS
For those who already had health insurance, premiums, deductibles and annual out-of-pocket maximums have increased, as insurance companies have had to provide a wider range of benefits and cover more conditions.
FINES FOR NOT HAVING INSURANCE
Some feel that it’s intrusive for the government to require health insurance, but the precedent was already set by our government requiring drivers to have insurance on automobiles. Under ACA, failure to show coverage can result in a modest fine.
TAX INCREASES
Several new taxes were created to fund the ACA, including taxes on medical device and pharmaceutical sales. The wealthy are helping to subsidize insurance for the poor, by being taxed at a higher rate.
COMPLICATED ENROLLMENT
The ACA website had many technical issues at its outset, making it difficult for people to enroll. Enrollment issues also forced hospitals and public health agencies to set up programs to help guide consumers.
CUTTING EMPLOYEE HOURS
Employers must now offer group insurance if they employ 50 or more workers who work 30 or more hours per week. This has led many big-name companies to limit employee hours to push them down to ‘part-time’ status, to avoid having to pay for group insurance.

There is a general confusion about the ACA, to the point where many cannot define the difference between it and Obamacare. The fact is – they are one and the same. The ACA is not a high-priced insurance plan with bad coverage for poor people, as it is often referred. The ACA is a law that forces Americans to be insured, and that forces insurance companies to insure them. With that in mind, let’s review how Tennesseans can get health insurance.

In Tennessee, most residents are insured in the following ways:

1. Employer Benefits
2. Medicare
3. Privately Obtained Insurance
This is insurance purchased from independent agents such as Farm Bureau, which offers medical insurance coverage based on the amount the consumer wants to spend
Consumers may opt for a short-term policy, paid in one up-front fee, that provides protection against medical emergencies that would lead to ruinous debt. This is commonly referred to as ‘catastrophic coverage’.
Consumers may shop for long-term policies, billed monthly, which offer coverage similar to employer coverage. These policies may have a $300 a month premium, with a $3,000 deductible and $6,000 per-year out-of-pocket maximum (for example).
4. Medicaid/TennCare
Nearly 1.5 million Tennesseans have TennCare, which is a state-ran Medicaid Program that provides health care with an annual budget of roughly $11 billion.
TennCare is one of the oldest Medicaid managed care programs in the US, dating to 1994.
TennCare services are offered through managed care facilities in several major Tennessee cities such as Nashville and Chattanooga.
TennCare has a Pharmacy Benefits Manager for coverage of prescriptions and a Dental Benefits Manager for coverage of dental services for children under the age of 21.
TennCare covers nearly 90% of medical costs for approved recipients.
TennCare is primarily restricted to low-income families, expectant mothers or mothers with young children, although expansions of the program have been considered which would broaden its reach.

The ACA requires Tennesseans to have insurance and, as you can see, there are different ways to enroll in the program that best works for your family. The most important thing, going forward, that Tennesseans must do is to fight against the movement to repeal Obamacare. The repeal of the ACA would set the medical insurance industry back ten years, when people were denied coverage by bottom-line/profit-minded insurance companies. It’s not by accident that some of the legislators fighting hard to repeal Obamacare – such as Tennessee’s 7th District US Rep Marsha Blackburn – have received millions of dollars in campaign contributions from the likes of Aetna, Humana and WellPoint. The medical and pharmaceutical industries are trillion-dollar enterprises and have money to spend on legislators who will fight for them and not for their constituents.

As your Representative, I pledge to do everything in my ability to maintain HIPAA, maintain the Affordable Care Act, and find new ways to improve health insurance coverage for every Tennessean and for every American.


© 2017 Dennis Potvin
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