Understanding the Affordable Care Act
Kathryn is in her early 50s and lives on the shore of Lake Washington with her husband, Bill, in an elegant contemporary home filled with sunlight and exquisite art. Bill, a successful entrepreneur, retired in his mid-50s. Bill and Kathryn* are too young for Medicare, but felt well protected since they had purchased one of the best health insurance plans on the market. She thought the Affordable Care Act a good thing—for other people who need help. As politicians argued about the merits and costs of “Obama Care,” Kathryn was aware of the debate raging in Congress, but thought neither she nor Bill would ever need it. She was wrong.
Bill developed a rare and aggressive form of cancer. With surgery, multiple rounds of chemotherapy and radiation treatments, and numerous hospital visits, Bill’s medical expenses totaled more than $1 million in under 12 months. The costs surpassed his policy’s annual cap for expenditures, as well as the lifetime cap. His health insurance was canceled. It was impossible to obtain new insurance. Not eligible for Medicare or Medicaid, Bill and Kathryn were on the brink of bankruptcy.
In a very up-close and personal way, Kathryn gets it now: Without the Affordable Care Act, preexisting conditions mean no access to health insurance—for some of the people who need it most.
Health care reform affects everyone (or will at some point in live) from prominent executives with company-paid medical plans loaded with benefits to employees who lose their insurance along with their jobs. Ditto for seniors, children, adults with preexisting conditions, those with serious illnesses, working moms and young adults. Some of its most important provisions, such as expanded coverage for children and young adults, are already in place, while the most significant changes are coming, beginning with open enrollment in a state-run health insurance exchange this fall and implementation in January of the “individual mandate” requiring everyone who can afford it to have health care insurance.
While other states hesitate to embrace reforms, Washington state is a leader in national reform efforts and has been experimenting with new approaches to health care for years—even before the passage of the Affordable Care Act—making Washington better prepared than most states to meet the challenges of implementing health care reform.
More than 10 years ago, Virginia Mason Medical Center became the first in the nation to adapt the lean principles of the Toyota Production System for health care. Called the Virginia Mason Production System, it enables the medical center to identify and eliminate waste, improve quality of care and patient safety, and lower the cost of care. In 2008, the Virginia Mason Institute was established to teach other hospitals and health organizations how to implement the lean principles. Virginia Mason chair and CEO Gary S. Kaplan, M.D., has testified before Congress and was ranked number six on the 2013 list of the “50 Most Influential Physician Executives in Healthcare” by Modern Physician and Modern Healthcare magazines.
Other local health care executives, such as Group Health Cooperative president and CEO Scott Armstrong and Everett Clinic CEO Rick Cooper also feature prominently in the national discourse on health care reform with their efforts to address challenges in primary care. And under the leadership of its executive director/CEO, Lloyd David, The Polyclinic, Seattle’s largest multispecialty, physician-owned practice, became the state’s first Medicare-approved accountable care organization in July 2012. Accountable care ties provider reimbursements to quality metrics and reductions in the total cost of care. The Polyclinic has experimented with accountable care models with health insurance companies such as Premera Blue Cross for several years.
Washington even “developed its own state-based health insurance marketplace to better meet the unique needs of the uninsured in our state,” says Richard Onizuka, chief executive officer of Washington Healthplanfinder.
At a Glance: Washington Healthplanfinder
Washington was one of the first states to receive conditional approval of its health plan exchange by the U.S. Department of Health and Human Services. “The exchange will be a one-stop shop, allowing consumers to make apples-to-apples comparisons between plans, determine eligibility for tax credits or less expensive copays and deductibles, and receive personal assistance in finding, selecting and enrolling in the right health plan,” says Richard Onizuka, chief executive officer of Washington Healthplanfinder (wahbexchange.org).
Key dates to remember:
September 1, 2013: Washington Healthplanfinder call center opens, providing detailed information about state exchanges to individuals, families and small businesses.
October 1, 2013: Open enrollment begins for coverage that starts January 1, 2014. The plans offered specifically for the exchange will only be available through open enrollment in the fall.
March 31, 2014: Enrollment period for 2014 closes. The next open enrollment period kicks off October 15, 2014. —S.M.