Implementation of health insurance exchanges, IPAB among key provisions to watch for
The recent U.S. Supreme Court ruling on the constitutionality of the Patient Protection and Affordable Care Act was interesting, to say the least. The ruling walked a fine line, but in the end the majority of the law was upheld.
The short version of the story is that the court ruled that the law’s penalty for not purchasing health care is constitutional because the penalty is actually a tax. In summary, the mandate is legal because Congress can impose a tax if one does not buy insurance.
This means that “community rating” for all health insurance policies, also a mandate in the law, is feasible and will be implemented.
The ruling will have significant political ramifications for the fall election, as you have likely heard. President Obama had gone to great lengths to characterize the mandate’s charge as a penalty and not a tax. The opponents of the law are going to press the message that this was a tax hike.
There was one significant strike-down by the court that may, in some states, impact the implementation of coverage for those with low income. The court ruled that the federal government cannot force the states into expanding Medicaid coverage by withholding current Medicaid funding if they do not expand as directed by the law. However, it does not prevent the feds from “enticing” states to participate in the expanded Medicaid coverage programs; they just cannot cut off other Medicaid funds if states choose not to participate. Many states will likely proceed with some form of Medicaid expansion to acquire the extra funds available.
All the other aspects of the bill are now the law with no changes. Entities such as medical homes, accountable care organizations (ACOs), and the Independent Payment Advisory Board (IPAB), among others, will remain unchanged.
What it means to you
What does this all mean to the practicing urologist? Here is an overview of what to expect in the months and years ahead.
Implementation of health insurance exchanges in the states. The mandate requires health exchanges to be set up in each state, allowing consumers to compare products. The federal government could take charge in setting up the health insurance marketplaces if the states refuse to do so. It is expected that individuals and small businesses will be able to use the exchanges to shop for insurance. Patients who have not been able to afford insurance because of pre-existing diseases will be able to buy insurance through the exchange. Once implemented, this will mean that your office will need to be vigilant in checking patient coverage for each visit, as some patients will change insurers for better pricing. Additionally, you may see more aggressive contracting from payers for your services. Know your place in the market and prepare to negotiate.
Expansion of Medicaid. States will play a key role in delivering new health insurance coverage to millions of lower- and middle-class people. However, many states have resisted, and the National Association of Insurance Commissioners expects only about half the states to be ready to set up new health insurance markets, slated to open for business in 2014. Some states have already implemented changes. Expect the implementation to vary from state to state. You can expect to receive payments for more patients, at Medicaid rates.
More patients with coverage. The court’s ruling upheld the mandate of coverage for millions of uninsured Americans. The “experts” who have predicted how many Americans will have to pay the tax for not purchasing health insurance disagree over the actual number. However, most expect an uptick in the number of people with insurance.
Community rating for all private insurance policies. The law’s requirement that most people buy insurance or pay a penalty if they fail to obtain coverage has been reported to be the essential trade-off the insurance industry sought in exchange for the law’s requirement that coverage be offered to people with pre-existing health conditions.
