In the two years since it was signed into law, the Patient Protection and Affordable Care Act has generated literally millions of news reports.
A Google search for “ObamaCare” turns up 25.7 million hits. That’s not quite Justin Bieber territory -- 679 million -- but still speaks to the level of attention the law has received. Yet, after all this time, and all those words, many Americans are still wondering: What’s in it for me and how will it change my health care?
Recently, I authored the Obamacare Survival Guide -- the first book offering consumers, business people, seniors, medical professionals, and others -- a practical understanding of the massive new law.
The answers, of course, are complex and depend on who you are -- a college student, senior on Medicare, uninsured, self-employed, have a pre-existing health condition, or get insurance through your employer.
But one thing is certain: ObamaCare will restructure the way health care is delivered in significant ways we will all feel. And regardless of your political views, whether you like what the law sets out to do or believe it is the wrong way to go, change is coming your way.
In fact, it’s already begun, with many provisions already in place, or soon to roll out, in the following five key ways that will alter health care for large blocs of Americans.
1. Medicare Changes
The presidential campaign has turned Medicare into a political football, with Democrats and Republicans each accusing the other side of seeking to cut or gut the federal government’s health insurance program for Americans age 65 and older and the disabled.
Under ObamaCare, Medicare reductions would add up to $716 billion in 10 years, according to the nonpartisan Congressional Budget Office. That figure is identical to Paul Ryan’s 2013 budget proposal. Health care experts believe those reductions will largely leave Medicare unchanged for Americans 55 and older. But the real changes come in 2022. Predictably, perhaps, Republicans and Democrats have different ideas about how to preserve Medicare down the road.
Those reductions in reimbursement to hospitals, insurers and the Medicare Advantage program (by about $68 less per month, according to the Congressional Budget Office) could lead to cuts in benefits and services for some seniors, even though ObamaCare does not specify what they might be.
Medicare changes also close the so-called “donut hole” in drug coverage, giving seniors a break on their out-of-pocket costs for medications. But other changes could occur to Medicare as a result of the new health care law that could affect their care and costs.
For instance, higher-income earners -- individuals earning $85,000 or higher, couples exceeding $170,000 -- will receive reduced subsidies to pay for drugs. ObamaCare also raises Medicaid payment rates to primary care doctors to Medicare levels in 2014, which some argue could dilute or compromise the level of care given seniors.
ObamaCare also creates a panel of experts, known as the Independent Payment Advisory Board, that be empowered to force Medicare cuts if costs rise beyond certain levels and Congress fails to act. Although the law explicitly prohibits the board from rationing care, shifting costs to retirees, restricting benefits or raising the Medicare eligibility age, critics believe the IPAB could recommend changes that could lead to rationing.
The board has yet to be named, and its members would ultimately have to be confirmed by the Senate.
2. Price Controls
Will ObamaCare limit soaring health costs for health care for most Americans? It’s too early to say for sure. But it seems unlikely, at least in the short run.
ObamaCare aims to cover uninsured Americans by expanding Medicaid and the “individual mandate” requiring everyone to have insurance or pay a tax. Those moves could hold down health care costs over time because many of the 37 million uninsured Americans seek care through hospital ERs for dire problems that are more costly to treat than prevent or manage (such as heart attacks, infections and complications from chronic conditions).
Costs are now borne by taxpayers and people with insurance.
ObamaCare proponents have argued people who have insurance are more likely to work with their doctors to manage chronic conditions -- such as diabetes, heart disease and cancer -- in ways that are less expensive up front than hospital care and may help head off serious problems down the road.
But since the law’s signing in 2010, costs and premiums have been increasing. According to the non-partisan Health Care Cost Institute, U.S. health care spending grew at a faster pace last year than in the previous two years, when increases in costs actually slowed.
Health insurers have also projected premiums will continue to rise -- at least 2 to 3 percent per year -- and nothing in the law bars insurance companies from passing along those increases to policy holders.
But the true acid test may be found in Massachusetts. Under the RomneyCare plan, the template for ObamaCare signed into law in 2006, the number of uninsured residents dropped to the lowest level in the country (3 percent), but insurance premiums have risen to the highest cost of any state in the nation for a family of four, according to the Commonwealth Fund.
3. Doctor Practices
One unanswered question about ObamaCare that could affect consumers: Will the law drive changes in doctor practices that could worsen physician shortages?
Polls of doctors suggest the answer may be yes. A survey of 2,400 physicians conducted in 2010 for the Physicians Foundation found 40 percent would “retire, seek a non-clinical job in health care or seek a job unrelated to health care” during the next three years. Investor’s Business Daily predicted as many as 360,000 physicians could leave the profession, based on a 2009 forecast survey of 1,300 doctors.
ACA supporters have argued the survey is not a true measurement of physician sentiment, since it came at the height of national debate over ObamaCare.
But the truth is no one can predict how the medical profession may respond to the coming changes. One thing is clear, however: The nation is already experiencing a doctor shortage, with the Associate of American Medical Colleges estimating by 2015 the nation will need 60,000 more doctors than the U.S. is expected to have. Adding another 37 million uninsured Americans to insurance rolls and Medicaid, as ObamaCare aims to do, is likely to add to the problems caused by existing doctor shortages.
4. Unwritten Provisions
Some impacts of the new law are unpredictable simply because many provisions have yet to be written and Congress must still authorizing funding for some of them.
For instance, federal health officials have yet to identify “essential health benefits” that insurers will be required to provide. Although experts expect those benefits will be comparable to what is now offered through typical employer-based health plans (that now cover about 150 million Americans), the details have not been determined. It’s also unclear how effectively the states -- or federal government -- will be in expanding Medicaid and creating new “health care exchanges” designed to will allow millions to purchase affordable, high-quality individual plans.
As we saw with the controversy over just one early provision of ObamaCare -- the question of insurance coverage for contraception, which the Catholic Church and others vehemently opposed -- many similarly contentious measures may be similarly difficult to resolve and implement.
5. Independent Payment Advisory Board
One controversial aspect of ObamaCare involves the creation of a presidential commission called the Independent Payment Advisory Board, or IPAB. This board of 15 experts, chosen by the president and approved by the Senate, will be empowered to cut Medicare spending and make other health care decisions independently, unless counteracted by a three-fifths “super-majority” vote in Congress.
The driving idea behind the IPAB’s creation is that the board would be able to make tough budgetary decisions that might be politically difficult for Congress or the president to implement (such as additional Medicare reductions).But because the IPAB won’t be elected, critics argue the board could wield enormous powers and increase government control over of the nation’s health care system.
As is true with many aspects of ObamaCare, the devil will be in the details of the law’s implementation. And, like the IPAB itself, ObamaCare is very much a work in progress.
The true test of the law’s viability will likely come in 2014, when ObamaCare’s most significant and costly provisions are implemented -- including the individual mandate that all Americans have insurance, the expansion of Medicaid, and the creation of the new state “health care exchanges” designed to give individuals without insurance through their employers or government programs the ability to choose affordable insurance plans with guaranteed “essential health benefits.”
Nick Tate is the author of the “ObamaCare Survival Guide: The Affordable Care Act and What it Means for You and Your Healthcare,” published by Humanix Books.