The holes in the health care law

April 13, 2011

Helen Redmond looks at Barack Obama's health care law after one year.

"HAPPY BIRTHDAY, Patient Protection and Affordable Care Act!" read the enthusiastic subject lines on millions of e-mails sent out last month by the union-backed Health Care for America Now coalition.

In Illinois, the Campaign for Better Health Care wrote in its celebratory statement: "It's been a year since the historic vote that made the Affordable Care Act a law, putting America on the path towards a system of quality, affordable health care for all. From birth to death, Americans now enjoy health care security and protection in new ways."

But is the one-year anniversary of PPACA, the health care law that President Barack Obama signed a year ago last month, something to celebrate? Is the U.S. really on the path to affordable health care for all?

Susan Aarup didn't celebrate last month--and she has to have doubts about whether she's on the path to quality affordable health care.

Aarup works as an employment advocate at Progress Center for Independent Living in Illinois and has been uninsured for eight months. Her job doesn't provide health coverage because she works part time, although she often puts in close to 40 hours a week. Aarup has cerebral palsy and uses a power wheelchair for mobility. She has two personal assistants who help her with everything, from bathing and cooking, to getting into and out of bed.

Patients wait for care at a public hospital
Patients wait for care at a public hospital

A month ago, a severe pain in her leg forced Aarup to the emergency room at Northwestern Memorial in Chicago. She was admitted to the hospital and diagnosed with a blood clot. Doctors said if she'd waited much longer, she could have died.

Why did she wait as long as she did? "Because I don't have insurance, and I don't have any money, I wait and I wait, and I hope it's not that bad," Aarup said. She didn't want to incur thousands of dollars in medical bills from an ER trip--which is exactly what happened. So far, Northwestern has billed her for more than $60,000.

Aarup is one of the tens of millions of uninsured in the U.S. who organizations like HCAN say will finally be covered because of last year's health care law.

But the insurance exchanges that are supposed to be a place to buy health coverage for those who don't have employer-based insurance won't phase in for several years. In the meanwhile, people like Aarup are supposed to be able to qualify for so-called "high-risk insurance pools" established as a temporary stopgap under the PPACA. The Illinois Comprehensive Health Insurance Plan (ICHIP) is the Illinois high-risk pool.

But Aarup can't afford ICHIP. Because the interim plans are still gender-, age- and smoking status-rated, Aarup was told she would have to pay a monthly premium of $575--only slightly less than the unaffordable $600 a month Aarup was paying for COBRA coverage before she become uninsured eight months ago.

Aarup applied for Medicaid, too--but was rejected. "I make too much money, and I work, so they don't think I'm disabled," she said, her voice full of frustration. "I'm caught in the cracks."

MEDICAID, THE federal government's health care program for the poor, is another aspect of health care in the PPACA era that should inspire not celebration but fear and doubt.

Under the health care law, Medicaid is to expand in 2014 to cover people with incomes up to 133 percent of the official poverty level. Currently, the poverty line for a family of four is $22,350 a year, so four-person households with an income of up to $29,725 a year would qualify.

The expansion of Medicaid is the health care law's solution for providing coverage for low-income people who won't be able to afford plans offered by private companies through the insurance exchanges. Medicaid will become the de facto insurer of millions of people--its expansion accounts for almost half of the projected increase in health coverage under the PPACA.

But the obvious problem is that the Medicaid program is full meltdown right now as state governments cut away at spending in order to balance huge budget shortfalls.

Arizona under Republican Gov. Jan Brewer has gotten some notoriety for eliminating Medicaid coverage for organ transplants--two people have died since the cut went through. Brewer plans to ax up to 120,000 current Medicaid recipients and introduce mandatory co-payments and benefit limits.

But Republicans aren't alone in going after Medicaid. New York's new Gov. Andrew Cuomo pushed through a state budget that slashes Medicaid--which serves about one in every four residents in the state--by $2.1 billion.

At the federal level, the Obama administration not only isn't defending Medicaid--White House officials are helping the states figure out how to cut. In a letter to state governors, Health and Human Services (HHS) Secretary Kathleen Sebelius assured them that the health care law will allow states to reduce Medicaid rolls if they face budget deficits. Sebelius suggested a range of cuts to "optional" benefits such as physical therapy, dental care, eyeglasses and prescription medications.

Compounding the funding problems are physicians who refuse to see Medicaid patients--in particular, specialists--because payment rates have been reduced, and further cuts are being proposed. A New York Times article interviewed a Louisiana nurse, Nicole Dardeau, who needs surgery for herniated discs, but can't find anyone who will perform it. "My Medicaid card is useless for me right now, it's a useless piece of plastic," Dardeau said. "I can't find an orthopedic surgeon or a pain management doctor who will accept Medicaid."

States seeking to cut costs are also privatizing Medicaid by forcing recipients into managed care HMOs. In Illinois, Democratic Gov. Pat Quinn wants to transfer half of beneficiaries into plans run by Aetna and Centene--even though managed care HMOs have a notorious track record of restricting access to care.

And this is all happening now. How will Medicaid handle an influx of 16 million people in 2014 if state governments can cut benefits and change eligibility rules at will, and doctors are refusing to accept patients?

MEDICAID EXPANSION is only one aspect of the health care law where problems are beginning to show up.

Another is the lobbying of federal agencies to "interpret" the provisions of the PPACA on terms that are most generous to insurers and Corporate America. For example, more than 1,000 corporations are still able to offer employees so-called "mini-med" health plans--stripped-down coverage that is inexpensive for workers to purchase, but that have benefits caps which would be easily used up by one hospital or even emergency room visit.

A provision of the PPACA requires insurers to gradually eliminate these kinds of annual caps on payments. But thanks to the Obama administration, giant corporations like McDonalds and Disney World are off the hook for now, because of waivers from HHS. "We don't want to take away people's health insurance before they have some realistic other choices," explained Sebelius.

Liberal Democratic Rep. Jan Schakowsky of Illinois skipped over another flaw in the PPACA at a celebration of the one-year anniversary last month.

Schakowsky told the crowd, "Raise your hand and give a shout out if you are a woman!"--before explaining that under the PPACA, being female was no longer a pre-existing condition and that inequality in coverage was a thing of the past.

What Schakowsky didn't mention was the provision in the law that will lead insurers to drop coverage for abortion procedures--a dramatic restriction on women's right to choose.

At the urging of anti-abortion Democrats, the health care law contains a provision that requires companies to separate coverage for abortions under policies they sell through the insurance exchange set up by the PPACA. Women will have to pay separately to be covered for abortions.

This arrangement is illogical because women don't plan to have abortions or complicated pregnancies that result in termination--but if they don't go along with the restricted coverage, they won't be covered when they need it.

Currently, 87 percent of private health insurance plans offer abortion coverage, but thanks to the Democrats' health care law, that percentage is bound to fall. "The PPACA extends the damaging effects of the Hyde Amendment into all health plans and will limit access to abortion for millions of middle class women," said Dr. Diljeet Singh, co-director of the Northwestern Ovarian Cancer Early Detection and Prevention Program and a member of Physicians for a National Health Program. "It further institutionalizes into national health policy the religious ideology and moral views of the minority."

Supporters of genuine health care reform are uncovering more holes in the health care law. For example, the PPACA doesn't forbid insurers from raising premiums--it only demands that they show that increases are deemed "reasonable" by state regulators. But in California, even if a rate hike is deemed "unreasonable," regulators don't have the power to block or modify it.

The truth is the Patient Protection and Affordable Care Act will not end the crisis in health care--far from it. Millions of people will be forced to buy "unaffordable underinsurance" from profit-hungry insurers who will receive billions in taxpayer subsidies. When they get sick, they will face the same nightmares--like being bankrupted by high premiums, deductibles, co-pays, gaps in coverage and uncovered services--that this law was supposed to end.

Meanwhile, Susan Aarup had to go to the ER again. This time she didn't wait. She thinks the American health care system is "insane."

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