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Seven things that could go wrong with health care reform

May 16, 2013
by Alison Knopf, Contributing Writer
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As implementation of the Affordable Care Act continues toward a January 2014 milestone, initial optimism has been muted by some very real concerns. So what could go wrong?

At present, the federal government is working hard to move health care reform from a long-planned effort into a working reality as January 2014, the date for the next major step in the process — the Medicaid Expansion — approaches. Millions of Americans are going to be educated in what hospitals and insurers have been working on behind the scenes for years. The reality for individuals is that many, for the first time, will have Medicaid coverage, while many others will have to buy health insurance via the state insurance exchanges (or marketplaces, as they’re now called).

Now that the Affordable Care Act's centerpiece -- expanded health insurance -- is almost a reality, employers and individuals alike are looking at their budgets, and sticker shock is setting in. That’s the big problem for the Administration: how to make sure people get enrolled via the marketplaces. But insurance companies have a problem as well – they don’t know how many of the people who enroll will be really sick and . And providers have a problem too – especially in the behavioral health field, where the promises of an influx of newly covered patients seem to be dimming with the lack of a final rule on parity, according to treatment advocates.

So, despite passage and gradual implementation of two historic pieces of federal health legislation — the Mental Health Parity and Addiction Equity Act (MHPAEA) in October 2008 and the Patient Protection and Affordable Care Act (ACA_ in March 2010 — there are plenty of things that could still go wrong with health care reform before January, 2014.

1. Weak Parity rules, or continued weak enforcement.The long-awaited final rule to implement the MHPAEA or “parity,” could be weak or weakly enforced, allowing some insurance companies and health plans to continue to interpret the law in ways that delay or deny coverage and payment for behavioral health care. This circumstance would have a domino effect: not only will it mean that people can’t get the mental health and substance abuse treatment they need, but that payers (and policyholders) would continue to bear the costs of excess physical health treatment for those with untreated mental illnesses and addictions, a cost estimated to be 25 to 33 percent higherthan those of patients without such conditions. (Alternatively, there could be poor enforcement of a strong parity rule. The interim final rule for parity that is already on the books, now suffers from weak enforcement, as neither the federal nor state governments appear to be leaving it up to private groups like the American Psychiatric Association to sue insurance companiesfor parity enforcement.)

2. Pricey premiums. Premiums could well be too expensive for employers and individuals. Sticker shock is most likely to affect people just above the federal limit for premium subsidies (the upper limit is 400% of the federal poverty level). Higher premium costs will also impact employed people who may find that their employer-provided health insurance benefits will go away, and that they must shift to the exchanges instead. Since premiums will be going up for everyone, employers are likely to take advantage of the ACA’s provision allowing them to cut workers to 30 hours a week in order to not keep them on the company plan. Subsidies will be available, but it’s unclear exactly how people understand the subsidies. According to one navigator, people will attest to their income when they sign up, and the insurance premium will be subsidized on the spot Then it will be reconciled at tax time in April.

3. A rush to coverage—by the sick. Only the sick will sign up, taking advantage of the ACA’s ban on excluding people with pre-existing conditions. This is what insurance companies consider a nightmare scenario, as it would maximize their costs for care while perhaps failing to add lots of new, healthy policyholders whose care costs would be much lower. The result: higher premiums for participants.

4. Absence of end-of-life planning. Because the ACA doesn’t address the cost of end-of-life care, those costs will continue to spiral, with Medicare doling out the majority of its dollars for the last weeks of life. Initially, there was a provision in the ACA that would have paid Medicare physicians to discuss and plan end-of-life (EOL) care. However, controversy about the rule and the rulemaking process, highlighted by Sarah Palin’s characterization of patient’s EOL discussions as “death panels,” put a quick end to this payment idea, though advance directives remain available to those willing to pay out-of-pocket for them.