What will happen if the ACA goes away?

Not everyone agrees with decisions made around the Affordable Care Act (ACA), but we can agree it changed history and affected the lives of all Americans. The ACA is not all good or all bad; there are positives and negatives, and pros and cons. Since its passage in 2010, we have been able to monitor and reflect upon its impact and give us the ability to separate fact from fiction.

FICTION: The ACA is socialized health care system and a first step to becoming a single payer healthcare.

FACT: The ACA is NEITHER. The ACA is a reform. It legislates provisions with the goal of covering more people by making private health insurance available and coverage more affordable.

FICTION: Persons not on Medicaid and Medicare will not be affected by the removal of the ACA.

FACT: ACA affects the provision of healthcare, insurance companies, and the health of all individuals across the U.S.

FACT: Implementation of the ACA increased access to occupational therapy services for individuals with disabilities who need rehabilitation, children born with disabilities who need habilitation, and other vulnerable populations.

FACT: The mandated regulations improved access to care and reduced the number of uninsured individuals from about 16% (48.6 million) in 2010 to 7.9% (25.6 million) in 2017 (Hellmann, 2018).

FACT: Since the removal of certain ACA regulations, such as the tax penalty for not having coverage, 2018 saw the first rise in the number of uninsured persons in the United States since the passage of ACA, up to 8.5% or 27.5 million (Botella, 2019).

FACT: If the ACA is repealed completely, occupational therapy services and the populations we serve will be significantly affected.

There is a lot of talk about the Affordable Care Act, and it can be difficult to make heads or tails of fact and fiction. It is imperative we learn from the past, focus on the present, and plan for the future. As health care professionals, our communities look to us for answers and guidance with health related decisions. It is our duty to provide accurate and evidence-based information to help guide independent decision making. It is equally important that the occupational therapy community advocate for our profession and the general population due to institutionalized health inequality. So let’s talk specifics. If the ACA is repealed completely, here’s a list of some of the changes that will take place

Here's what you will lose.

The ACA first implemented the policy that allows adult children to stay on their parents’ health insurance plans until the age of 26. If ACA is repealed in its entirety, this regulation would disappear, leading to an increased number of individuals between the ages 22-26 without health insurance.

Let’s say you had an emergency surgery, were in a serious accident, diagnosed with a serious illness, or experienced medical complications that put you out of work. You were hoping to get back to work as soon as possible, but unforeseen circumstances kept you home, and unpaid. Medical bills start piling up, and you have no other option but to apply for Medicaid.

Currently, under ACA, Medicaid could pay for your recent Medicaid covered health care services; this is called retroactive Medicaid coverage (Justice in Aging, 2019). Retroactive Medicaid coverage ensures government financial assistance for eligible health care services up to three months before the Medicaid application is submitted. However, if the ACA is repealed, people will no longer receive this retroactive coverage, and Medicaid would be unable to cover those services, leaving people and their family members responsible for their entire bill. This removal will not only affect the individual, but will add unnecessary strain to hospitals and medical practitioners, as they may not be reimbursed for their services. A snowball effect will take place, leading to premature discharge, falls, and an increase in readmission rates, all of which cost medical systems time and money. Other than the possibility of losing the roof over your head, this will lead to a delay in SNF admissions, and unnecessary strain on hospitals and medical practitioners. Hospitals bills may be denied, and may result in an increase in premature discharge, due to lack of coverage.

Currently, insurance companies are required to pay for 10 essential health benefits.

1. Ambulatory patient services
2. Emergency services
3. Hospitalizations
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Rehabilitation and Habilitation (Services that help patients maintain, or improve skills necessary for daily functioning) and devices
7. Prescription drugs
8. Laboratory services
9. Preventive and wellness services and chronic disease management.
10. Pediatric services, including oral and vision care (Families USA, 2018).

So what if insurance companies are no longer required to cover these services? Well, insurance companies will be allowed to sell plans that do not cover bills such as an ambulance ride, or an ER visit. It will also be up to the insurance companies to decide if they want to cover desperately needed mental health and substance abuse services. Insurance companies would no longer be required and my be unwilling to cover occupational therapy services, medications, prescribed lab work, and/or a child’s oral or vision care. Without regulations in place, this will lead to confusion, surprise medical bills, and debt that far too often put families in financial strain.

As an essential health benefit, habilitation and rehabilitation services, greatly increases access to occupational therapy services. Rehabilitation includes rehab that helps you return to everyday living after injury or life disruption, while habilitation is rehabilitation that provides services to individuals born with disabilities, including but not limited to children with autism, cerebral palsy, and intellectual disabilities. To help shine a light on the importance of this required benefit, here is an example of its’ impact:

In an awful accident, Mom fell and broke her arm. After surgery and weeks in a cast, she is prescribed Occupational Therapy to regain strength and range of motion in her arm. Since her accident, she’s been having trouble keeping up with hobbies, chores, and playing with her dogs. Both Mom and her doctor assume therapy is covered under her insurance. Mom shows up for the initial evaluation, and finds that OT is not covered. Mom is expected to pay full price for the evaluation and all subsequent visits and has to decide whether to forgo therapy, or try to find the money to cover the OT services.

As required by the ACA, insurance companies must provide coverage for habilitation and rehabilitation services. Without this requirement, Occupational therapists could lose reimbursement for services. Additionally, the loss of coverage increases barriers to accessing care.

Under the ACA, all Medicare recipients are entitled to a free annual physical. Without these screenings, individuals will miss the opportunity to prevent potentially life threatening/ contagious diseases, threatening the health of individuals and overall public health.

Occupational therapy practitioners work with a wide variety of clients from the acutely ill, to otherwise healthy individuals, who need an ergonomics consultation. Preventable or manageable comorbidities affect an individual’s ability to recover from illness and stay well. Everyone benefits when their community is healthy, but this is unachievable without prevention.

Medicare Part D currently closes what was known as the doughnut hole. The doughnut hole refers to an arbitrary gap in prescription drug coverage that existed under Medicare Part D, before ACA. Medicare participants who purchased $2850 worth of prescription drugs would have no more coverage for prescription drugs until they spent a total of $4550 for their prescription drug coverage to kick back in. In other word, Medicare enrollees would have to spend $1700 in medications out-of-pocket, before prescription drug coverage will kick back in (see Figure 1). Hence the gap in coverage, was referred to as the donut hole. ACA slowly closed the donut hole, reducing the amount of out-of-pocket gap in Part D drug coverage.

If ACA is repealed, the donut hole/gap in coverage returns. For some, $1700 is manageable, but many would have to choose between their medication and their mortgage or rent. Many people choose their mortgage or rent, leading to otherwise preventable death and illness. This is particularly true for individuals who need insulin, blood pressure or cardiac medications, medication to treat mental illness, and cholesterol medication.

Prior to the ACA reform, insurance companies could place a cap on the amount of money they were willing to spend on an individual’s health care. In other words, the insurance company could place a limit on the maximum coverage they will provide before it declines further coverage. If the medical bills went over that imposed limit, the insurance company would no longer have to provide an individual with health insurance coverage. When the ACA was first enacted, it provided insurance plans could no longer have these limits on coverage. The people who need this coverage are the people who need care the most. If the ACA is no longer the law of the land, insurance companies could reinstate these limits and deny coverage to the individuals who need medical care the most.

Here is an example of the consequences caused by lifetime limits: Jake considers himself a healthy person; he doesn’t need to go to the doctors any more than his annual physical. However, at his last physical, his doctor sees his blood work is off. Jake’s doctor orders more tests, and he finds out he has cancer. Jake goes to an oncologist and finds out he’ll need surgery, chemotherapy, and all sorts of rehab. Before he knows it, Jake’s reached his lifetime limit, and his insurance company is no longer willing to cover his medical bills. Jake is left needing to choose between paying out of pocket, or forgoing medical treatment.

Risks:

• Return of annual lifetime limits and the amount of insurance one has
• Individuals with chronic and severe diagnosis could be denied healthcare because they reach an annual or lifetime limit
• Inability to receive Occupational Therapy services
• Encourage the return of “junk plans” (Plans that don’t really cover anything

Currently, insurance companies have to provide autonomy and give patients the right to choose their own primary care doctor, as long as it is within the company’s network. There are several risks associated with the removal of this provision:

Risks:

• Limit the number of doctors patients are allowed to see
• Increase in wait times
• Limited number of open appointment time slots
• Increase travel time to see a doctor

The ACA made obstetrics and gynecology care more accessible by allowing clients to see an OB-GYN provider without a referral from a primary care doctor. Some primary doctors will send over a prescription if you call and ask for one, but many others ask their clients to come in and be seen first. Not only does this take extra time off from work, etc., this costs insurance companies and clients extra money, requiring a primary care appointment that may be unnecessary. People would often rather avoid the extra time, money, and effort, and may end up skipping both doctors appointments altogether. This is a good example of a waste of money and resources that can be spent elsewhere.

This provision prohibits discrimination in relation to both the provision of health care services and insurance coverage. This included discrimination based on race, color, national origin, sex, age, disability or LGBTQ status. In June of this year, the Health and Human Services (HHS) Department proposed “substantial revisions” to this provision.

By narrowing the provision’s scope, the revisions suggested include:

• Eliminating protections against discrimination based on gender identity
• Eliminating protections against discrimination for transgender individuals
• Eliminating protections against health insurers from discrimination against certain groups, such as people with HIV or LGBTQ people
• Allowing abortion and religious freedom exemptions for health care providers so health care providers do not have to treat women who have had abortions or other people based on their religious believes
• Weakening protections for interpretation and translation services for individuals with limited English proficiency
• Eliminating provisions affirming the right of individuals to challenge violations of Section 1557 in court
• Narrowing the reach of the regulations by only covering specific activities that receive federal funding, but not health insurers, and no longer applying the regulations to all HHS programs (Kaiser Family Foundation, 2019).

A key provision of the ACA is a requirement that all health insurance policies cover specific preventative services. Below is a list of some of the covered preventative services, separated by age group.

Adults:

• Immunization vaccines
• Screenings for several illnesses and infections
• STI and HIV
• Aspirin
• Mammograms every 1-2 years for women over 40
• Contraception and contraception counseling

Children:

• Immunizations
• Behavioral and developmental assessments
• Iron and fluoride supplements
• Oral health risk assessment
• Hearing and other screenings for newborns
• Screenings for autism, vision impairment, Lipid disorders, tuberculosis, lead exposure, obesity, and certain genetic diseases
• Screenings for adolescents for depression, HIV and STI, cervical dysplasia, and alcohol and drug use

If the ACA is repealed in its entirety, insurance companies may no longer cover these services, and consumers may need to pay full price for these services. There are numerous risks associated with no longer covering these preventative services, including but not limited to: increased accidental pregnancy including teen pregnancy, increased risk of sexually transmitted infections, including HIV, and decreased early detection of genetic disorders, certain cancers, and a multitude of other health concerns. When people can’t pay for, or are not provided with preventative services, there is an increased risk of disease, illness, and health epidemics, all of which increase the chances of decreased function and early death.