February 2012 Ask the Expert: Healthcare Reform

February 1, 2012

After a breast cancer diagnosis, anxiety about healthcare coverage can be almost strong as concerns about your diagnosis. As the Affordable Care Act (ACA), often called the healthcare reform law, begins to change the health insurance landscape, how does this new law impact you now and in the future?

During the month of February, Living Beyond Breast Cancer expert Hillary C.M. Nelson, PhD, MPH, answered your questions about how healthcare reform impacts you as a woman diagnosed with breast cancer.

Question: Can my insurance company cancel my policy or charge me more because of a breast cancer diagnosis?

Dr. Nelson: Based on the Affordable Care Act, your insurance company cannot cancel your policy just because of a breast cancer diagnosisinfo-icon.

There are some caveats. For example, if you had neglected to tell them about a prior health problem directly related to your new breast cancer diagnosis (like a previous bout with cancer), then they would have the right to “rescind” or cancel your policy due to misrepresentation. However, they cannot cancel your policy for having made an honest mistake on your application.

In addition, your insurance company cannot charge you more during your plan year for a breast cancer diagnosis. Your insurance company could raise the rates for your next plan year, but there are now new limits. Your insurance company cannot increase rates in general by more than 10 percent without having the reasons for the rate increase reviewed either by your state’s Rate Review program or the federal Rate Review program. Any rate increases must be fair – that is, they must charge similar rates to people who pose similar risks to the insurer.

Until 2014, insurance companies can charge different rates based on health risk. However, after 2014, insurance companies will not be able to discriminate based on any health risk, with the sole exception of tobacco use.

Question: I was just diagnosed with breast cancer and I don't have insurance. How can I get coverage? What are my options?

Dr. Nelson: After 2014, there should be no problem getting coverage because insurance companies will not be able to deny coverage to people with pre-existing conditions. Until then, the Affordable Care Act has helped states develop interim insurance plans for people with pre-existing conditions.

There are some caveats – one major one is that you have to have been denied coverage for a pre-existing conditioninfo-icon AND have been without health insurance for six months. In addition, many states have separate programs to help people in your situation, including programs specific for women with breast cancer.

You can find specific information about the insurance plans that you might qualify for at HealthCare.gov It will walk you through your current insurance options.

Question: I heard that under the new healthcare law everyone will be required to have health insurance. Is this true? If so, how will this work, when will it be available and how much will it cost?

Dr. Nelson: Starting in 2014, most individuals will be required to purchase a basic health insurance policy. There are exceptions, including the inability to afford health insurance and specific religious exemptions. At the same time, there will be an increase in the availability of federally- or state-subsidized insurance programs. The Affordable Care Act calls the requirement for purchasing insurance an “individual responsibility,” but the requirement has popularly been called a mandate.

The reason for the mandate is simple: spreading healthcare costs to everyone. Remember that the basic definition of an insurance policy is to pool premiums to spread financial risk. Starting in 2014, insurance companies will no longer be able to charge more for people with pre-existing conditions or deny coverage to anyone, even if they have a pre-existing conditioninfo-icon. This means, theoretically, that everyone could wait until they got sick before purchasing health insurance. This would generally wreak havoc with the health insurance system. In order to avoid this AND to keep costs reasonable for everyone, the Affordable Care Act included the mandate.

How will this affect you? If you currently purchase insurance through your employer and your employer continues to offer insurance plans (as most will), then nothing will change. If you purchase insurance outside of your workplace, then you will be able to purchase insurance through state-based Affordable Insurance Exchanges.

The Exchanges will be a competitive marketplace, with multiple insurance companies competing for individual business. Unfortunately, the exact rates won’t be known until the Exchanges start. However, there will be a range of options, generally varying by premium costs, co-pays and deductibles. This should ensure that everyone finds insurance coverage that makes sense for their situation.

Question: How does the Affordable Care Act affect Medicare recipients?

Dr. Nelson: Under the Affordable Care Act, Medicareinfo-icon recipients will actually see enhanced services, especially as relates to preventiveinfo-icon services and screenings such as mammograms, cervical cancer screenings and vaccines for influenza, pneumonia and hepatitis B, to name a few. Most of these preventive services and screenings will be free—that is, no co-pay or deductible. To help with this, you will have an Annual Wellness Visit to coordinate your preventive care.

The Affordable Care Act is also working to strengthen the Medicare Trust Fund by going after waste and fraud and implementing cost-saving measures. The government has already started to attack fraud: Last week, federal officials shut down one of the largest Medicare fraud schemes ever seen. The cost-saving measures will come from better coordination of care, especially with respect to hospitalizations, so that Medicare recipients will avoid harmful—and costly—re-admissions for the same conditioninfo-icon. At the same time, hospitals will be offered incentives to improve the quality of care to Medicare recipients, another initiative that is expected to save money. Reducing waste and fraud, along with the cost-saving measures, are expected to prolong the solvency of the Medicare Trust Fund.

Question: What about Medicaid? What changes have occurred or will occur in the future?

Dr. Nelson: The Affordable Care Act will provide more federal matching funds to states for their Medicaidinfo-icon programs. This has already allowed states to expand their eligibility to more individuals and families.

Beginning in 2014, the Affordable Care Act will expand eligibility for Medicaid to all Americans who earn less than 133 percent of the poverty level. To facilitate this, states will receive 100 percent federal funding for three years in order to cover these newly eligible Medicaid recipients.

Question: I have heard that health care will be "rationed" under health reform. I won’t be able to get certain tests or procedures. What if I want those tests, and what if they detect something that could save my life?

Dr. Nelson: I have read the entire legislation of the Affordable Care Act. There is no “rationing” under health reform.

This misconception has occurred because the Affordable Care Act has strengthened the role of the U.S. Preventiveinfo-icon Services Task Force (USPSTF), an independent panel of non-federal experts that conducts reviews of scientific evidence on preventive health care service. The USPSTF reviews all studies on tests and procedures and makes recommendations about whether they are effective and safe for the populace.

Those preventive tests that receive an A or B gradeinfo-icon must be covered without cost-sharing by insurance companies (with the conditioninfo-icon that services are received in network).  That is not to say that insurance companies won’t cover additional preventive services, but they are not required to do so without cost-sharing if the USPSTF does not recommend that they are safe and effective.