Your quick and dirty guide to the Patient Protection and Affordable Care Act (the ACA, aka Obamacare)

We drafted this for our interns based on a presentation I've been giving for years. Posting it here for anyone who might find it helpful while Congress debates the ACA's future.

Health Insurance 101

• Half of Americans get their health insurance through their employer
• The other half are insured through the government, through the individual market, or have no coverage at all
• You may have heard of terms like “socialized medicine” (Great Britain), “single payer” (Canada), and private health insurance. In the US, we have all three:
• Socialized health care: the government operates health care facilities and employs health care professionals. Examples include hospitals, clinics, and doctors that are owned, operated, or employed by the Indian Health Service, the Defense Department, and Veterans Affairs
• Single payer: health care services are provided by private businesses but paid for by the government. Examples include Medicare (seniors), Medicaid (low-income patients), and TRICARE (military personnel)
• Multi-payer: health care services are provided by private businesses and paid for by private health insurance companies. Examples include health insurance provided by employers and health insurance purchased through the individual market, including ACA marketplaces

The ACA is built on top of this existing structure, which has existed since World War II. The ACA takes a two-track approach to reforming the system:

1. Improve coverage for everyone, and
2. Help people without affordable, quality insurance get it

 Track 1 — Improve coverage for everyone, including those who get insurance through their job

(whispers: you probably“have Obamacare”)

• Eliminate annual and lifetime caps on benefits
• pre-ACA, a prematurely born newborn could use up her lifetime coverage before she even left the NICU
• Prohibit discrimination based on pre-existing conditions, gender, and more
• pre-ACA, insurers often charged non-smoking women more than smoking men, even for plans that didn’t include maternity care,
• and they treated rape and domestic violence as pre-existing conditions
• Crack down on “rescissions”
• pre-ACA, insurers could revoke your coverage as soon as you got sick
• Cap out-of-pocket expenses
• Require plans to cover basic essential health benefits such as prescriptions, mental health care, ER services, and maternity care
• Make preventive care (e.g. checkups, vaccination, contraception, cancer screening, etc) free from co-pays or additional costs
• Require plans to cover dependent children up to age 26
• Require insurance companies to put 85% of the premiums they collect toward health care, ensuring that premiums don't rise simply to pay CEO salaries and bonuses

 

 Track 2 — Help people without insurance through their job get quality coverage

1. Expand Medicaid to insure the poorest and most vulnerable Americans

• Original or 'traditional' Medicaid (first enacted in 1965) is sometimes described as “poor and...” because to qualify, an individual must be a) poor and b) also fall into another category, i.e. poor and pregnant, poor and disabled, poor and a child, poor and elderly, and so o.
• The federal government covers 57% of the cost (on average) for traditional Medicaid; states cover the rest.
• Medicaid expansion is for low-income individuals who don’t fall into one of those additional categories. In expansion states, Medicaid is open to all low-income citizens who don’t qualify for original Medicaid.
• The federal government pays 90% of the cost; states cover the remaining 10%.

2 - Help low-income households purchase private insurance in the individual market

• One set of subsidies helps individuals pay their monthly premiums, while another keeps co-pays and deductibles low
• Each state’s insurance market has a ‘Travelocity-style’ site to make comparison shopping between plans easier
• Healthcare.gov directs patients shopping for coverage to the marketplace in their state

2012 Supreme Court Decision and Its Impact on ACA

When the ACA was enacted, it required every state to expand Medicaid to all low-income adult citizens. But in 2012, the Supreme Court ruled that each state could decide on its own whether or not to expand. The majority of states expanded Medicaid, but in the 19 states that refused, there’s a coverage gap for the poorest Americans in their states.

Because the ACA was drafted under the assumption that Medicaid expansion would be mandatory, there's no mechanism under the law for extending coverage to those living below the poverty line in states like Texas and Florida that have chosen not to expand Medicaid for partisan reasons. The technical policy term for those stuck in the coverage gap: shit outta luck

Changes We’re Working On

While the ACA has helped over 20 million people gain insurance coverage—many for the first time in their lives!—and improved women’s physical, mental, and financial well-being, the current health care system is still far from perfect.

People who don’t qualify for subsidies and don’t get insurance through an employer struggle to afford plans on the individual market. Some local marketplaces have too few insurance plans offered on the individual marketplace, leaving consumers with extremely limited choices. Insurance costs are also particularly high in rural marketplaces. (These problems aren't limited to the ACA, however. They're also a problem in the Medicare Advantage program, which pre-dates the ACA and is championed by Republicans.) The Medicaid expansion gap leaves millions without coverage. Access to abortion coverage is limited, with states able to impose draconian coverage prohibitions. Prescription drug prices, which were never addressed in the ACA at all, continue to rise. And by design, the law leaves undocumented immigrants without access to Medicaid or marketplace subsidies, and put delays on access for other immigrants. (There's no public health rationale for this choice, it's purely political.)

The promising aspect of all these issues is that they are fixable. We continue to push for improvements that will give affordable access to the full range of health care care to all women and LGBTQ individuals, regardless of their income, documentation status, geographic location, or other current barriers to care.

Finally... Bet You Didn’t Know the ACA Contained this Too

• Requirement that restaurants with 20+ locations prominently post nutrition information
• Requirement that companies with 50+ employees give nursing women “reasonable” break times to pump and a private space (not a bathroom) to do it
• Requirement that drug and device makers report their financial relationships with health providers
• Scholarships and loan forgiveness for students who become nurses and primary care doctors
• Numerous carrots (incentives), sticks (punishments), pilot programs, grant programs, and research funds to reduce repeat hospitalizations, move to electronic health records, reduce unnecessary tests, help smokers quit, reform the medical malpractice system, improve public health (‘adulthood’ training, oral health, sex ed), research postpartum depression, and more