Affordable Care Act Primer

What you need to know about Washington's new insurance marketplace

Kathryn thought the Affordable Care Act would be a good thing—for other people who need help. As politicians argued about the merits and costs of “Obamacare,” she was aware of the debate raging in Congress, she says, but thought neither she nor her husband, Bill*, would ever need it. She was wrong. Bill developed a rare and aggressive form of cancer, and his medical expenses totaled more than $1 million in fewer than 12 months. His health insurance was canceled; the couple was on the brink of bankruptcy. (*Kathryn and Bill's names have been changed for privacy.)

Bill developed a rare and aggressive form of cancer, and his medical expenses totaled more than $1 million in fewer than 12 months. His health insurance was canceled; the couple was on the brink of bankruptcy.

In a very personal way, Kathryn gets it now: Without the Affordable Care Act, patients can lose their health insurance, just when they need it most. Her experience also illustrates how health care reform potentially affects everyone, not just the uninsured.

Since the passage of the Affordable Care Act (ACA) in 2010, some of its most important provisions are already in place, including protection from the insurance industry’s worst abuses, the introduction of preventive care and access to health insurance for vulnerable groups, such as children and young adults. Health insurance companies can no longer cancel coverage if someone becomes seriously ill. Lifetime medical limits are now illegal. Annual checkups and some preventive care are no longer subject to copayments or deductibles.

The ACA’s most significant changes are yet to come, however: As of January 1, 2014, most Americans who can afford it will be required to have health insurance. Those who already have insurance they like don’t need to make any major changes in 2014; but those who want a change or don’t have insurance can now shop for new options through the Washington Healthplanfinder (wahealthplanfinder.org). At press time, the Office of the Insurance Commissioner had approved four insurance companies to offer 31 health plan options for individuals and families. Those who don’t have affordable coverage from their employers and who buy through the state exchange may be eligible for help with insurance costs, depending on family size and income level.

The exchange’s plans have a defined set of essential benefits, including preventive care, pediatric care and maternity care. Washington state legislators also voted to expand Medicaid to include individuals between the ages of 19 and 65 with incomes up to 138 percent of the federal poverty level, also effective as of the new year, making health care available to most adults in our state.

“The care that many of us take for granted, such as treatment for a sinus infection, provider visits to manage diabetes or exams for breast cancer detection, are luxuries to those without health care coverage,” HealthPoint pediatrician Kimberly McDermott, M.D., says. “These families are one illness away from financial catastrophe.”

Not only is the infrastructure of health care changing, but over the last few years providers have been shifting the way care is delivered in ways that anticipate an influx of new patients. Group Health Cooperative introduced the medical home model, a patient-centered approach using teams (doctors, nurses, physician assistants, pharmacists, etc.) to care for patients. “Primary care physicians who manage a patient’s care with specialists, hospitals, and pharmacists will be especially important as new patients come into the market,” says Rick Cooper, CEO of The Everett Clinic. “Many will have chronic conditions, such as diabetes and heart disease.” Comprehensive and coordinated care will ensure better health at lower costs.

Although it’s still too early to tell what will actually be accomplished with health care reform, “In an ideal world, this legislation would increase access to care, improve quality and make health care more affordable,” Cooper says. ✚

The Sign Up Timeline: Washington Healthplanfinder

Washington Healthplanfinder allows consumers to shop for and compare health care plans offered by government-approved insurance companies. Here are some of the key dates for consumers:
October 1, 2013: Open enrollment began for coverage that starts on January 1, 2014. The plans offered specifically for the exchange are only available through open enrollment in the fall.
March 31, 2014: Enrollment period for 2014 closes. The next open enrollment period kicks off on October 15, 2014.

Comments