The New HealthCare Law: A Synopsis of the Real Changes and Timelines
Posted by Matt Owens on Sun, Jul 25, 2010
(Editorial Note: These statements were gathered from sources including major insurance companies, rights advocacy groups and internet news sites. They are not binding or law provisions and should not be used for legal or accounting purposes. These compiled opinions do reflect the opinion of the compiler, Kerry G. Belcher, Sr., Operations Manager for The Belcher Group of Insurance Agencies in Southwest Virginia, Eastern Tenn, Eastern Kentucky, Southern West Virginia. You may reach me at 276-865-5144 for comments or questions).
The health reform package is made up of two parts: a bill that passed the Senate on Christmas
Eve, passed the House on March 21, and was signed into law by the President on March 23, and
a second piece of legislation: the House’s reconciliation bill, which makes changes to the original
law, passed both chambers on March 25, and was signed by the President on March 30.
Many of the provisions in the law will not take effect for several years. At the earliest, provisions
that affect employer-sponsored health plans will take effect six months from the date of
enactment – in late September. Even then, those early provisions will not affect plans until
they renew for the next plan year.
The health reform law has thousands of pages and hundreds of provisions. So it’s important to
remember that before many of those provisions are put in place, additional laws and regulations
will need to be developed. That could be a lengthy process.
Here are some highlights of the major provisions.
Individual responsibility
Starting in 2014, everyone must have coverage or pay a penalty, which will be enforced
by the Internal Revenue Service. The penalties will be phased in over time:
• In 2014, an individual without insurance must pay whichever amount is greater:
$95 or 1 percent of income.
• For 2016 and beyond, that penalty rises to $695 or 2.5 percent of income, whichever
is greater (the $695 is indexed from 2016 on).
• Families will pay half the penalty for children, with a cap of $2,085 per family.
• There will be exemptions to this requirement, such as in cases of fi nancial hardship
and other limited circumstances.
Subsidies to buy insurance in new state exchanges will be available in the form of tax credits
and cost-sharing assistance for people above Medicaid eligibility but below 400 percent of
the federal poverty level. Medicaid eligibility will be increased to 133 percent of the federal
poverty level.
New employer penalties and obligations
Starting in 2014, employers don’t have to offer their employees health insurance coverage, but
most of them with more than 50 employees will pay an assessment if they don’t, or if they offer
coverage that isn’t affordable. Full-time and part-time employees are included when determining
whether an employer has 50 employees (based on current full-time employee equivalency rules).
• Employers with 50 or more employees that do not offer “minimum essential coverage” will
pay $2,000 for each employee over the fi rst 30 employees if one of their employees gets a
tax subsidy to buy insurance under an exchange.
• Employers with 50 or more employees that do offer minimum essential coverage but have
at least one full-time employee receiving subsidized coverage under an exchange will pay
whichever is less: $3,000 for each employee receiving a premium credit, or $2,000 for each
full-time employee.
Employers must provide “free choice” vouchers to employees with incomes below 400 percent of
the federal poverty level if the employee’s contribution to coverage is between 8 percent and 9.8
percent of income and the employee chooses to purchase coverage in the exchange. No penalties
will be imposed on employers with respect to employees who receive these vouchers.
Employers with more than 200 employees that offer coverage must automatically enroll new
full-time employees in coverage. Employees may opt out.
New employer reporting requirements
• Beginning in 2011, employers will be required to disclose the value of health care benefi ts
on an employee’s annual W-2.
• Employers will be required to notify employees:
– About the availability of the exchange – for new employees, at the time of hiring;
for current employees, by March 1, 2013;
– They may be eligible for a subsidy under the exchange if the employer’s contribution
to the plan is less than 60 percent of total allowed costs of the benefi ts;
– If the employee purchases coverage in the exchange, he or she will lose the employer’s
coverage contribution.
• In 2014, large employers will be subject to expanded 5500 reporting requirements
to include information on the health insurance coverage of their employees.
Small business tax credits
Beginning in 2010, small businesses with fewer than 25 employees and average wages of less
than $50,000 get a tax credit for their contributions to buying health insurance for employees.
The tax credit starts at up to 35 percent and increases to 50 percent in 2014 when the exchange
is operational. A full tax credit may be available to small businesses with fewer than 10 employees
and average wages of less than $25,000.
Health plan changes
Under the new law, individuals and employers/employees have the right to keep the coverage
they had as of March 23, 2010 and are exempt from many reforms. These individual and group
health plans are considered “grandfathered plans.” Collectively bargained plans that were ratifi ed
before the date of enactment are grandfathered until the date that the last collective bargaining
agreement related to coverage ends.
IMMEDIAT E LY:
• Federal rate review. The Department of Health and Human Services (HHS) will
establish a process for federal review of fully insured premium rate increases.
I N 9 0 D AY S :
• Internet portal. By July 1, an Internet portal will be created for consumers and small
businesses to shop for health Insurance.
• High-risk pool. $5 billion has been appropriated to create a temporary high-risk insurance
pool to help adults with pre-existing conditions get coverage if they have been uninsured for
six months. The program will be effective through 2013.
• Reinsurance for early retirees. A temporary reinsurance program will be established for
employers providing coverage to early retirees over age 55 who are not eligible for Medicare.
The federal government will provide $5 billion to fund the program. Participating employers
or insurers will be reimbursed 80 percent of retiree claims between $15,000 and $90,000.
The program will be effective through 2013.
I N S I X M O N T H S :
Effective for new plans and plans renewed six months after the law’s
enactment date, unless otherwise noted (includes “grandfathered plans”):
• Lifetime and annual limits. Plans may not impose lifetime limits on the dollar value
of essential benefi ts. Annual limits will be restricted (to be determined by HHS). Restricted
annual limits do not apply to grandfathered individual plans.
• Rescissions. No rescissions are permitted, except in cases of fraud or intentional
misrepresentation.
• Coverage for adult children. Children may stay on their parents’ policies until age 26 if
coverage isn’t available through their work, regardless of their marital status. Any employer
contribution toward the premium for a child through age 26 is a tax-deductible business
expense for the employer and not taxable income for the member.
• Pre-existing conditions. Plans may no longer impose pre-existing condition exclusions for
children under 19 (does not apply to grandfathered individual plans).
Effective for new plans and plans renewed six months after the law’s
enactment date (does not include “grandfathered plans”):
• Preventive services. New policies must cover the full cost of preventive care as recommended by
the U.S. Preventive Services Task Force, recommended immunizations, preventive care for infants,
children and adolescents, and additional preventive care for women.
• Appeals. New minimum requirements for internal and external claims appeals processes.
• Patient protections. Plans that require or provide for a primary care provider (PCP)
designation must allow each member to designate any in-network PCP, or pediatrician for
children, accepting new patients. Plans may no longer require an authorization or referral to an
Ob-Gyn. Prior authorization or increased cost-sharing for emergency services is also prohibited.
• Nondiscrimination rules. Nondiscrimination rules that apply to self-funded health plans are
expanded to group fully insured health plans. Plans cannot base an employee’s eligibility or
continued eligibility on hourly or annual salary.
I N 2 0 1 1 :
• Medical loss ratio (MLR). An insurer must publicly report on its MLR and spend at least 85
percent of large group premiums and 80 percent of individual and small group premiums on
medical services, or provide rebate payments to enrollees.
• Spending accounts. Health savings accounts (HSAs) and fl exible spending accounts (FSAs)
may no longer be used to purchase over-the-counter drugs unless prescribed by a doctor.
Increases tax for nonqualifi ed HSA withdrawals from 10 percent to 20 percent, and for
Archer MSA withdrawals from 15 percent to 20 percent.
• HHS studies. HHS is required to study the group health plan markets to compare employer
characteristics and determine whether the new insurance market reforms are likely to cause
adverse selection in the large group market or to encourage small and midsize employers to
self-insure. HHS and the Department of Labor must also collect information on self-funded
plans. These studies could lead to additional employer reporting requirements.
• Uniform explanation of coverage. Within 12 months of the law’s enactment, HHS, in
consultation with the National Association of Insurance Commissioners, will develop uniform
standards and defi nitions for summaries of benefi ts and coverage explanations. Within 24
months of enactment, group health plans must provide enrollees and applicants with coverage
documents that meet these standards.
I N 2 0 1 2 :
• Comparative effectiveness fee. A new fee is imposed on individual and group health
plans to fund comparative effectiveness research ($1 per participant through 2013; $2 per
participant through 2019).
• Release of Medicare claims data. The private sector may purchase standardized data
extracts of Medicare Parts A, B and D claims data to combine with their own claims data to
evaluate provider performance measures on quality, effi ciency, and the effectiveness of care.
I N 2 0 1 3 :
• FSA contributions. Contributions to flexible spending accounts are limited to $2,500 a year.
I N 2 0 1 4 :
The federal defi nition of a large employer is an employer with 101 or more employees, whereas a
small employer is defi ned as 1-100 employees. States can modify the defi nition of a large employer
to 51 or more employees and small employer to 1-50 employees until January 1, 2016.
• Pre-existing conditions. Individual and group health plans can no longer impose
pre-existing condition exclusions for any person of any age (does not apply to grandfathered
individual plans).
• Annual limits. Annual limits on essential health benefi ts are prohibited (does not apply
to grandfathered individual plans).
• Guaranteed issue. Health insurers must accept every individual and employer who applies
for coverage.
• Rating restrictions. Rating restrictions go into effect for new individual and fully insured
small group plans. Insurance companies cannot base premiums on health status, claims
experience or gender. Premiums can only vary by:
– Age (no more than 3:1)
– Geography
– Family size
– Tobacco use (no more than 1.5:1)
• Merged markets. States are allowed to merge the individual and small group markets.
• Clinical trials. Coverage of routine patient care costs is mandated for participation in
approved clinical trials (does not apply to grandfathered plans).
• Exchanges. State health insurance exchanges are up and running for small businesses and
individuals to buy insurance. States can allow large employers to participate beginning in 2017.
• Brokers. HHS will establish procedures, which may include rate schedules for broker
commissions, for a state to allow brokers to:
– Enroll individuals in any qualifi ed health plans in the individual or small group market as
soon as the plan is offered through an exchange in the state;
– Assist individuals in applying for premium tax credits and cost-sharing assistance for plans
sold through an exchange.
• Essential benefi ts. Essential benefi t plan is created, which mandates the level of benefi ts
that must be included in plans offered in the exchange, as well as in the individual and small
group markets outside the exchange. Deductibles are limited to $2,000 for individuals and
$4,000 for families in the small group market (self-funded plans and grandfathered plans are
exempt from this requirement).
• Cost-sharing limits. Cost sharing imposed under health plans is limited to current health
savings account amounts (does not apply to grandfathered plans).
• Waiting periods. Waiting periods cannot exceed 90 days.
• Wellness. Expands health plan wellness incentives up to 30 percent of total coverage costs
(up to 50 percent with HHS approval).
• Reinsurance. A temporary reinsurance program will be established for the individual market
and funded by individual and group health plan assessments ($25 billion in 2014-2016).
I N 2 0 1 6 :
• Health choice compacts. States can form health choice compacts to allow insurers to sell
individual policies in any state participating in the compact.
I N 2 0 1 8 :
• Taxes. A new excise tax goes into effect for high-value, “Cadillac” health plans: 40 percent
for amounts over $10,200 for individuals and $27,500 for family plans, paid by insurance
companies and plan administrators.
Medicare and Medicaid-related provisions
• Part D donut hole. Provides a $250 rebate for Part D enrollees who enter the “donut hole.”
coverage gap (2010 only). Beginning in 2011, there will be a 50 percent brand discount on
drugs in the gap. Members will pay less for generic drugs in the gap as well: 93 percent in
2011, which phases down to 25 percent by 2020. The donut hole is eliminated by 2020.
• Retiree drug subsidy. Beginning in 2013, employers may no longer deduct the retiree
drug subsidy when offering qualifi ed coverage under Medicare Part D.
• Medicaid. Beginning in 2014, states are required to provide premium assistance and
wrap-around benefi ts to any Medicaid benefi ciary who is offered employer-sponsored
coverage, if it is cost-effective to do so.
• Medigap. The National Association of Insurance Commissioners will create new model plans
for benefi t packages C and F that include nominal cost sharing. The new models will be
available in 2015.
Other
• Administrative simplifi cation. The law also requires HHS to adopt a single set of operating
rules for electronic transactions to create uniformity (e.g., health claims or equivalent
encounter information, eligibility and claims status, enrollment and disenrollment, premium
payments, and referral certifi cation and authorization). Group health plans will have to
certify compliance with these standards.
• CLASS Act. Creates a new government-run voluntary long-term care insurance program
(CLASS Program). Employers must automatically enroll employees and facilitate payroll
deductions. Employees may choose not to participate.
Revenue-raising provisions
• Starting July 1, 2010, imposes a 10 percent tax on tanning services.
• Beginning in 2011, the pharmaceutical industry will pay annual industry fees. The fee will
be phased in and will hold steady at $2.8 billion a year after 2019.
• Beginning in 2013, manufacturers of medical devices will pay a 2.3 percent excise tax on
sales of medical devices.
• Beginning in 2013, the Medicare payroll tax rate will increase by 0.9 percent for individuals
who make more than $200,000 and couples that make more than $250,000.
• A new 3.8 percent tax will be added on income from interest, dividends, annuities, royalties
and rents for those at the same income threshold.
• Beginning in 2014, a non-deductible premium tax will be imposed on insurers and
third-party administrators ($8 billion in 2014, $11.3 billion in 2015 and 2016, $13.9 billion
in 2017 and $14.3 billion in 2018. After that, it will increase in an amount proportional to overall premium growth.
If I retire this year, what type of medical coverage can I get before Medicare kicks in?
A. Your options will depend on whether or not you are eligible for early retirement benefits through your employer. Since 1993, the percentage of large employers offering health insurance to retirees 55 to 64 years old has fallen from 46 percent to 28 percent, says Paul Fronstin at the Employee Benefit Research Institute in Washington, D.C. That’s meant that waiting to join Medicare has been the only option for many early retirees, since the high cost of individual policies is out of reach for many people with fixed incomes, and especially for those with preexisting health conditions.
The new law is about to expand these choices.
First, it would encourage employers to continue to cover younger retirees by giving companies $5 billion to companies to help pay the insurance bills of these men and women until they are eligible for Medicare at age 65.
This new program, which begins June 1, would affect about 2 million early retirees who still get health coverage through their former employers, says Fronstin. Some 4,500 employers are expected to apply for the money, which will be available until 2014—when health plan exchanges begin operating—or until the money runs out.
The program is beginning about three weeks ahead of schedule, Rep. John Dingell, D-Mich., said in a letter urging employers in his district to apply for the assistance. Dingell is the longest-serving member of the House of Representatives and a longtime advocate of health care reform. He also reminded employers that the federal aid comes with strings attached and can’t be used as ordinary general income.
There is some additional help for retirees and those considering early retirement, whose employers don’t offer health care benefits.
Under the health care reform law, people unable to buy their own coverage because of preexisting health conditions will be able to do so in a few weeks through high-risk pools, explained below. In addition, Congress extended eligibility for another federal program called COBRA, which allows laid-off workers to continue their employer-sponsored health coverage for 18 months by paying the total cost—both the employer’s share plus their own premiums. Congress also provides unemployed workers a 65 percent federal subsidy for the first 15 months of their COBRA policy. The U.S. Department of Labor offers more details about COBRA and the subsidy.
Q. Under health care reform, will a Muslim be required to buy health insurance, if not already covered? There are a lot of rumors and misinformation flying around the Internet about this.
A. The health care reform law requires that adults buy health insurance starting in 2014. The law also provides subsidies in the form of tax credits to defray the cost for those with moderate incomes and opens Medicaid to more low-income individuals and families. People who don’t comply will have to pay a penalty.
However, the law provides an exception to the rule for members of religious groups opposed to accepting insurance benefits that pay for medical care. It gives the Treasury Department the job of setting up an application process for handling exemption requests.
Not much else is certain at this stage. It will be a while before the agency spells out these steps in regulations, since the insurance mandate doesn’t take effect for three more years, a Treasury spokeswoman said.
We can clear up one thing: No matter what you may have heard or read on the Internet, the spokeswoman confirmed that no religious groups have received or been promised exemptions.
Q. I hear that seniors get $250 for medicines if they fall into the doughnut hole. When do we get this, and how? When do we get rid of the gap in coverage?
A. The new law requires the federal government to send seniors enrolled in Medicare Part D drug plans a $250 check if they hit the limit for drug expenses this year and fall into the coverage gap, or “doughnut hole.”
“You don’t have to do anything,” says Vicki Gottlich, senior policy attorney at the Center for Medicare Advocacy in Washington. You should get a check within three months after the quarter of the year in which you entered the gap. So if you fall into the gap in July, which is in the third quarter of the year, you should get a check by the end of December. The first checks are due to be mailed June 15.
Currently, going into the gap means paying 100 percent of the cost of your drugs out of your own pocket until your expenses reach a certain limit. But beginning next year, the doughnut hole will slowly shrink:
- You will get a 50 percent discount on brand-name and biologic prescription drugs that you buy in the gap in 2011. Starting in 2013 the federal government will gradually add to these discounts so that by 2020 you will be paying no more than 25 percent of the cost.
- Generic prescription drugs will get a 7 percent price cut starting in 2011. By 2020, the federal government will cover 75 percent of the cost of these drugs. By 2020, the gap will disappear. It’s important to know that the discounts do not affect your ability to qualify for catastrophic coverage if the actual costs of your drugs are high enough to reach that level.
Q. Does the new law make it easier to get long-term care health insurance?
A. The health reform law creates the country’s first government-run long-term care insurance plan, to help people pay for the assistance they need to live independently and stay out of expensive nursing homes. Unlike private long-term care insurance, there’s no limit on how long you can get benefits, and you can’t be turned down because of a preexisting health problem. The monthly premiums never increase if you’re 65 or older and have paid into the plan for 20 years.
“It’s a benefit for life,” says Connie Garner, policy director for disability and special needs populations for the Senate Committee on Health, Education, Labor and Pensions. She worked side-by-side with the late Sen. Ted Kennedy to help write these provisions, known as the Community Living Assistance Services and Supports (CLASS) Act.
The CLASS plan provides a cash benefit of at least $50 a day, and it increases payments depending on the recipient’s degree of disability. The benefit can be used for a wide range of nonmedical items or services, from grab bars for the bathroom and other home modifications to hiring a home care aide or paying for transportation. The person you hire to provide care can be a friend or relative, Garner says.
Here’s how it will work:
- By about the end of 2012—but more likely in 2013—employers who decide to participate will begin deducting premiums for this insurance from the paycheck of any worker over 18 years old—but employees can opt out of the plan if they wish. Other arrangements will be made for people who are self-employed, unemployed or whose employers decline to participate.
- The Congressional Budget Office estimates that the monthly premiums would average about $123 for someone 50 to 55 years old, based on a benefit of $75 a day. Garner says that premium will be lower for a younger person and higher for someone older. The actual premium has not been determined.
- Monthly costs of the insurance can only be adjusted based on age, not health status.
- The money from these premiums will accumulate in a separate fund to pay for future benefits.
- You become eligible for benefits after paying into the plan for five years, and working three of those years, earning at least $1,200 a year. You must be working when you enroll. The five-year waiting period was necessary in order to have enough money and participants to pay benefits, Garner says.
- To receive the benefit, you must need assistance in at least two of five activities of daily living, such as eating, dressing or bathing, or need supervision because of a mental impairment like Alzheimer’s disease. A health care provider must certify that your disability is expected to last more than 90 days.
- Garner says the government benefit can be combined with your own long-term care policy. It can also be used in combination with Medicaid, to offset the cost of nursing home care. People who receive services paid by Medicaid outside a nursing home can keep half the benefit, she says.
Many details have yet to be spelled out in regulations, which are instructions on how to implement the provisions Congress approved. Here are a few things we don’t know yet:
- What will the premiums be? That will depend on how many people join the plan and whether they are in good or poor health.
- How much will the benefit be, and how high will it range?
- What level of need must you have in order to get the maximum benefit? The CLASS plan is for everyone, says Garner, “whether they’re under 65 and they fell off the ladder taking down their Christmas lights, or they have functional limitations as a result of the aging process.”
Q. I am 67 and have two daughters, one is 18 and the other is 20. Can they be covered by my health plan? If so, when does this take effect?
A. Starting Sept. 23, 2010, the health care reform law gives college students a graduation present. They won’t lose their health coverage just because they are no longer in school or they’ve reached the current age limit under their families’ health plan. They can stay on their families’ insurance until their 26th birthday.
If I retire this year, what type of medical coverage can I get before Medicare kicks in?
A. Your options will depend on whether or not you are eligible for early retirement benefits through your employer. Since 1993, the percentage of large employers offering health insurance to retirees 55 to 64 years old has fallen from 46 percent to 28 percent, says Paul Fronstin at the Employee Benefit Research Institute in Washington, D.C. That’s meant that waiting to join Medicare has been the only option for many early retirees, since the high cost of individual policies is out of reach for many people with fixed incomes, and especially for those with preexisting health conditions.
The new law is about to expand these choices.
First, it would encourage employers to continue to cover younger retirees by giving companies $5 billion to companies to help pay the insurance bills of these men and women until they are eligible for Medicare at age 65.
This new program, which begins June 1, would affect about 2 million early retirees who still get health coverage through their former employers, says Fronstin. Some 4,500 employers are expected to apply for the money, which will be available until 2014—when health plan exchanges begin operating—or until the money runs out.
The program is beginning about three weeks ahead of schedule, Rep. John Dingell, D-Mich., said in a letter urging employers in his district to apply for the assistance. Dingell is the longest-serving member of the House of Representatives and a longtime advocate of health care reform. He also reminded employers that the federal aid comes with strings attached and can’t be used as ordinary general income.
There is some additional help for retirees and those considering early retirement, whose employers don’t offer health care benefits.
Under the health care reform law, people unable to buy their own coverage because of preexisting health conditions will be able to do so in a few weeks through high-risk pools, explained below. In addition, Congress extended eligibility for another federal program called COBRA, which allows laid-off workers to continue their employer-sponsored health coverage for 18 months by paying the total cost—both the employer’s share plus their own premiums. Congress also provides unemployed workers a 65 percent federal subsidy for the first 15 months of their COBRA policy. The U.S. Department of Labor offers more details about COBRA and the subsidy.
My husband and I are in our late 50s and have a health insurance policy with a very high deductible that only covers catastrophic care. We pay high premiums and have no preventive-care coverage. Will the new law help us afford better health insurance? We are living on the edge—any more bills and we fall off.
A. The new law will lower the monthly cost of insurance in 2014 by providing tax credits or refunds to reduce the cost of your premiums. The credits are available to people whose income is in a certain range and who are eligible to buy coverage through the new state-run health insurance exchanges. You can buy basic comprehensive coverage through an exchange if you don’t have insurance or if your insurance is unaffordable. (How the exchanges work will be explained in an upcoming answer.)
Because it’s too early to know what the insurance premiums will be in 2014, we don’t know how much the credits are worth in dollars. We do know that the credits will be a percentage of your income, from 2 to 9.5 percent, if your income is under a certain level—the current range would include individuals with incomes of $14,403 to $43,320 and families of four with incomes of $29,326 to $88,200.
In addition, new consumer protections will take effect in September that can also help make coverage more affordable. For people who buy new group and individual policies, insurers cannot set lifetime limits on how much they will pay, cannot cancel policies after you get sick, and cannot exclude children with preexisting medical problems. And certain preventive screenings and vaccinations will be provided at a price that can’t be beat: free.
Q. I’m over 50 and have been turned away by health insurers who either won’t sell me coverage or charge so much I can’t afford to buy it, all because of my health problems. How long do I have to wait before I can get covered?
A. If you have preexisting medical conditions and have been unable to get health insurance for at least six months, you should be eligible to buy coverage through a temporary federally funded program called a “high-risk pool.” Under the new law, this option—expected to be available by July—will cover about 2 million men and women in your situation. Older members cannot be charged more than four times what younger members pay for this coverage, and out-of-pocket expenses are limited to $5,950 for an individual or $11,900 for a family this year.
Among the states participating in the program and sharing $5 billion in federal aid are California, Michigan, Montana, New York, Pennsylvania, Washington, and Wisconsin. New York officials have said the state will be eligible for as much as $297 million in federal aid, while California expects a potential $761 million. States opting out include Georgia, Indiana, Minnesota, Nebraska, Nevada, and South Carolina. The federal government will operate the program in those states that don’t participate.
How much premiums will cost to join the high-risk pool, available subsidies, which hospitals and doctors will participate, and exactly what will be covered are among the key details yet to be worked out. For the latest information – including whether your state is in or out – contact your state department of insurance (for the telephone number, call the National Association of Insurance Commissioners’ consumer hotline at 1-866-470-6242).
This program ends in 2014, when insurance companies will be required to sell policies to anyone, regardless of their preexisting medical conditions.
Q. I’m having trouble now finding a primary care doctor. Will it be harder for me to get one when millions more people get health insurance because of this new law?
A. While 32 million people will eventually be added to the rolls of the insured, that won’t happen overnight or in one fell swoop. It will take time, and about half will be insured through state health insurance exchanges, which won’t open until 2014. But you are right—it can be hard to find a primary care doctor who will accept a new patient, especially as the nation’s population grows older and demand increases. During the health reform debate, Republican critics such as Florida Sen. George LeMieux warned that a physician shortage could undermine the entire reform effort: “It’s not health care reform if the doctor is not in,” he said.
The new law addresses the shortage of primary care doctors in three basic ways.
• First, primary care doctors who treat Medicare patients will receive an extra 10 percent bonus from 2011 to 2016, and earn another small bonus if they file health care quality reports with Medicare. In addition, the law adjusts Medicare payments to reflect the variations in medical costs by geographical area, which the American Medical Association says will benefit doctors in 42 states.
The measure also raises payments for family physicians who treat patients in Medicaid, the government’s health care program for low-income people. And it reduces paperwork for doctors who treat Medicare and Medicaid patients—another sweetener to entice physicians into the programs.
• The second way the law tackles the shortage is by providing incentives for doctors to go into the primary care field. For example, it expands loan forgiveness programs to defray the cost of medical school and provides money for primary care training programs at teaching hospitals.
It also provides grants to medical schools to recruit and train students who will practice medicine in rural communities. There are similar incentives for training nurses and other medical providers, which should help ease the demand for primary care doctors.
• Finally, the law encourages changes in how patients are treated by creating “accountable care organizations”—physician and other medical groups—which will be paid according to how well the patient fares, rather than the number of services provided, explained Jean Silver-Isenstadt, M.D., executive director of the National Physicians Alliance. “This means that issues that can be handled over the phone, will be, and patients won’t be required to come in for an office visit just to ensure the physician gets paid,” she said. “This will free up valuable time for doctors to see more patients.”
No one knows for sure whether bonuses and other changes will build up the supply of primary care doctors fast enough to keep pace with demand.
Susan Jaffe has written about health care reform for Health Affairs and covered aging issues for the Cleveland Plain Dealer.