Tuesday, August 21, 2012

The ACA and you.

How has the Affordable Care Act impacted you? Details, please, the more the better. I had that conversation last week with a research team doing a study on this very thing. How does the implementation of the ACA impact families, does it? For the better? Why? 
That’s a trickier question then it seems. Of COURSE it impacts my family, but it's more of a big picture thing. The pre-existing condition clause is huge for us. The knowledge that Henry won't get denied coverage based on his health history, that even if we something happened to affect our employer sponsored health insurance, he would be ok. But is that enough? Is that a compelling story? That's the same story as every other kid with a pre-existing condition. What else is there about us...about how the ACA helps us?  

Well.... let me think. And that's where I landed. Thinking. See that's the thing, I accept my private health insurance, I pay the premiums and assume when they deny me coverage for something it's because it's not really that important, or a necessary part of my health care. But, and you see where I'm going with this, what gives them the right, my INSURER the right to determine what is a necessary part of our health care?  In particular, Henry has been repeatedly denied coverage for Physical Therapy and Occupational Therapy because they are "developmental" and not related to a particular injury. "Good news" I said when I met with their appeals board, he did have an injury, he had a stroke. Because his stroke was in utero, it's considered congenital, so any therapy related to that injury would be "developmental".  Ah.  Clear as mud.  "But our Primary Care doctor prescribes us to see a PT and OT, and the CP clinic and Gait clinics we attend are all covered by insurance, just not the actual therapist visits?" Yep. Denial of appeal letter appeared in my mailbox the next day, though they still did accept the premium payment in my next paycheck. 

And this is where the ACA could really change things. Right now, states are deciding what their minimum level of coverage will be when the ACA kicks in. They’ll determine coverage for many areas of treatment, from preventative to palliative, but what matters to us, each state will set their own definitions for the minimum coverage requirements for rehabilitative services like OT and PT and whether they’ll be required to cover developmental services. It’s the state legislators that will actually decide, on a state by state basis, what the ACA will mean for their state. And this is where you can make a difference. As this process goes forward, there will be countless meetings held, presumably behind closed doors, where this coverage is hammered out, and that's when it will be critical that your legislators understand what your needs are and why.  The implementation of the ACA could force my private insurer to start covering what my doctor tells them is a necessary part of Henry's healthcare. Finally. 

And that's the thing with the ACA. It's so big, and so much of it is getting rolled out a section at a time, and then some of it is getting implemented by the states and some by the federal government and there's a whole lot of misinformation getting thrown around. So people take the nugget that pertains to them, cling to it, and either love or hate the ACA because of that nugget. And I'm no different, I preach the benefits of the pre-existing condition clause to anyone who stops long enough to listen. But because I'm so focused on that nugget, I don't see the rest of the treasure. Elimination of annual and lifetime coverage limits of benefits (critical to a person with a lifetime of medical needs before them). Young adults having the option to stay on their parents health insurance until they are 25 (more than 25% of working age persons with disabilities are living in poverty). Health insurance companies that are required to spend your premium dollars on healthcare and not on their profit margin (um... yeah, I'm pretty sure our family isn't good for anyone's profit margin). I recognize that some politicians claim Obamacare is the first step to socialized medicine, that a for-profit insurance business is the only way to keep costs competitive and that just doesn't make sense to me. That clearly didn't work. So why keep doing the same thing? 

I'm excited to learn more about what the ACA can do for our family, and more importantly, how I can help impact that on a state level through advocacy and education. I look forward to that journey, and to sharing it with you every step of the way.  

Hug your kids/partner/pet and have a great night, 


1 comment:

  1. I by no means understand this as much as you. However, I have a nephew who's "birth mom" and I use the term mom very loosely here, in short attempted to drink herself into a miscarriage when she was pregnant. (Long Story) Regardless, he was adopted into our family by Scott's sister and was recently diagnosed with Fetal Alcohol Syndrome which despite brain damage most things for his condition are classified as behavioral. Which I happen to disagree with. Behavioral to me means something you have control over, something that can be taught, trained, mimicked, etc. When you lack that ability it should no longer be classified as behavioral. Despite the fact doctors were skeptical of his ability to function as a "normal" boy he can walk, talk, etc and is one of the most amazing and inspirational children I've ever met. Your post made me think: What if their insurance doesn't cover all the therapy he needs to grow and live a comfortable life? It would be incredibly expensive and why doesn't he deserve those things without cost being an issue? Now I have no clue about their insurance, but I do know that the pre-existing clause will undoubtedly help him in years to come.

    Related to that same clause I coached a girl in high school softball. She will be entering her second year in college and was recently dropped from her insurance company because she was considered "high risk" as she has a serious kidney condition. So because she is high risk they are going to strip her of health care..ummm ya that makes sense. I don't know if this law will change that but it should. She is 20 years old, how do they justify that?

    Last but not least Scott and I have had our 4 child and unless something odd happens we decided Addison will be our last. So I had the talk with my OB doctor about birth control and for now I'm on a safe oral pill while I breastfeed and then I'll explore other options. So I walk up to the pharmacy knowing I wouldn't have a co-pay because our expensive insurance plan has $0 generics. However this time the pharmacist stated, "There will be no charge today either due to your prescription plan or new legislation which would cover this for you." Then I looked at the label for 3 months of birth control pills it would have cost me $78 out of pocket without insurance or the new law?! For a pill they mass produce and is as common as bubble gum. That doesn't make sense to me either. Exploring more permanent birth control options I read my textbook of an insurance policy handbook, and called member services twice and have received 3 different answers as to what they will cover. Ridiculous. As an FYI: Scott & I carry an individual health care plan at GHC.

    I loved this post, as I do all of yours, and I agree to take what pertains to you and those you love. It's not a battle worth fighting if it's not for what you love.