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Obamacare: What Was and Wasn’t Said at the DNC

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“They want your vote, but they won’t tell you the plan.”

Those were President Barack Obama’s words last night in Charlotte, NC, describing the distinction between himself and his opponent, Governor Mitt Romney. But it’s not just a Republican disease to leave the details of future plans vague during campaign season. We all know the Affordable Care Act, better known as Obamacare, means a second Obama term will see revolutionary reforms to the American health care system. So what, exactly, did he say about that?

A little girl in Phoenix can get the surgery she needs:

Obama did make a few indirect mentions of the ACA in his speech. He said that the days were gone when the attitude was “if you can’t afford health insurance, hope that you don’t get sick.” He affirmed his commitment to Medicare: “Yes, we will reform and strengthen Medicare for the long-haul,” Obama said. “But we’ll do it by reducing the cost of health care. Not by asking seniors to pay thousands of dollars more.” He added that “no American should have to spend their golden years at the mercy of an insurance company.” And in a classic campaign speech touch, he made reference to a little girl in Phoenix, who could now get the surgery she needed because an insurance company could no longer limit her coverage. He was referring to a new provision of the ACA that has already been enacted, which prohibits insurers from imposing lifetime limits on policies.

The end of lifetime limits has made it into the real world — but we’re still waiting on the end of annual coverage limits (scheduled for 2014), among many, many reforms still to come. The Democratic released their party platform recently in conjunction with the convention, and it too highlighted certain provisions of the ACA that have already been rolled out.

But what are we still waiting on? The run up to an election seems like a tricky time to be bringing more controversial provisions to life, such as the individual mandate (requiring the uninsured to buy health insurance, or pay a penalty). So what has been done, and what is still left to do?

These are the reforms mentioned in the Democratic Party Platform:

Reforms Highlighted in the Democratic Platform What Changed
Young Americans entering the workforce can stay on their parents’ plans Regulations from the Dept. of Health and Human Services required insurers to allow young adults to stay on parents’ plans until the age of 26. Began Sept. 23, 2010.
Insurers no longer refuse to cover kids with pre-existing medical conditions Health problems that developed in children before applying for coverage are not grounds for refusal of coverage, or limitation of coverage. Started one plan year (12-month period after your coverage start date) after Sept. 23, 2010.
Insurers will no longer be able to arbitrarily cap and cancel coverage Lifetime limits — the amount an insurer will cover over the life of the policy — are prohibited as of Sept. 23, 2010. Restrictions on annual limits — what an insurer will pay per year — went into effect for job-related and individual plans issued after Mar. 23, 2010, and are set to be phased out completely by Jan, 1, 2014.
Insurers will no longer charge women more because of their gender Misleading — the end of medical underwriting will stop this in 2014. However, the ACA has already changed healthcare for women in other ways (see below).
Private plans offer more preventative services Private plans were required to cover birth control, well-woman visits and other female healthcare costs as of Aug. 1 2012.
Established new Offices of Minority Health The OMH was created in 1986, but reauthorized in 2010 by the ACA. The ACA established six new branches of the OMH within other government agencies, such as the Dept. of Health and Human Services.
Helping State Medicaid Programs fund home and community-based services A new state plan option under Medicaid to encourage primary care providers to offer community-based services for chronically ill Medicaid enrollees. Announced April 23, 2012, the pilot program began June 1, 2012 and will run until May 31, 2015.
Small Businesses are receiving tax credits to help them cover their workers From 2010-2013, a small business employing less than 25 full-time employees with an average wage of $50k or less a year that offers at least half the employees health coverage is eligible for a 35% tax credit. It goes up to 50% in 2014.
Businesses and families are receiving rebates from insurers who overcharged them Insurance companies who spent more than 20% of premiums on administrative and advertising costs have begun to issue refund checks to policyholders. Companies had to refund $1.1 billion in premiums by Aug. 1, 2012, according to news reports.
Insurers no longer able to deny coverage based on preexisting conditions This is offered now under the Pre-existing Condition Insurance Plan, a transitional program which will end in 2014, replaced by nationwide guaranteed issue.
Medicaid will cover more working families Not existent yet — expansions of Medicaid still to come.
Those who don’t get coverage through their employer will be able to shop in exchanges and will be eligible for new tax credits Not existent yet — this will happen with planned exchanges in 2014.

Compare that with an overview of the reforms still to come from the ACA, below. These are some of the overarching concepts of the legislation, as well as specific reforms taken from the What’s Happening And When timeline on Healthcare.gov:

Reforms Still To Come, Not Mentioned What Must Change
Guaranteed issue/end of medical underwriting Small and individual plans will no longer be allowed to charge higher premiums using medical underwriting (meaning basing premium amount on the age, health or gender of the insured). Effectively means insurance companies can’t charge more for “riskier” individuals. Begins Jan. 1, 2014.
Medicaid expansion States can expand coverage to individuals making 133% of the Federal Poverty Level. Originally slated for 2014. SCOTUS decision said states don’t have undertake this expansion, however. States such as Florida and Texas have indicated opposition. CBO/JCT estimate no state will complete by 2014.
Creation of state exchanges States must offer exchanges, where individuals can use tax credits to purchase coverage. States can create their own exchanges, or revert to a Federal Exchange. To roll out Jan. 1, 2014.
Creation of Federal exchanges Federal government must also create an exchange model. Also slated for Jan. 1, 2014.
Individual mandate enactment People who are eligible for purchasing coverage on exchanges must do so, or pay a penalty. SCOTUS upheld, citing lax enforcement mechanism as proof of Constitutionality. To begin 2014, with exchanges.
Increase in Medicare reimbursement rate to primary care doctors Federal government will pay primary care physicians no less than 100% of Medicaid costs in 2013 and 2014.
CLASS – expansion of long-term care insurance This reform, designed to help consumers cover long-term care costs in the event of becoming disabled, was canceled by the Dept. of Health and Human Services in Oct. 2011, due to a lack of viable funding options.
Standardized billing and making health care documents electronic New regulations will reduce healthcare’s reliance on paper records, in order to decrease provider costs. First regulations came out July 2011, mandated date for compliance is Jan. 2016.
Value-based purchasing program A new program to incentivize hospitals to offer high quality care for in-patient acute care of Medicare enrollees. Slated to begin Oct. 2012.
Expansion of funding to state medicaid programs for preventative care Provides new funding to state Medicare programs that offer preventative care services to enrollees. Will begin Jan. 1, 2013.
Bundling of care A pilot program for Medicare to incentivize hospitals to bill Medicare according to “episodes of care”, rather than fragmented services. Starts Jan. 1, 2013.
Additional funding to CHIP The Children’s Health Insurance Program (CHIP) will get funding for 2013 and 2014. CHIP covers children who don’t qualify for Medicaid yet cannot afford to buy insurance.
Insuring coverage for clinical trials In 2014, insurance companies can no longer drop coverage because an individual chooses to participate in a clinical trial of a new medication or treatment.
Eliminating annual limits Prohibits insurers from setting annual limits to the amount of coverage they will provide. Starts Jan. 1, 2014.
Paying physicians on value, not volume One of the last provisions of the ACA with an official implementation date, physicians are going to be reimbursed based on the quality, not quantity, of care they provide. To begin Jan. 1, 2015.

This comparison makes a strong case for something Obama himself repeated many times in his speech: “America, I never said it would be easy.” Unfortunately, almost all the meaty reforms of the ACA are still ahead — with just a few of the pain free and people-pleasing tweaks already in place. You might have gotten a rebate check for 80 bucks in the mail, but you haven’t been told to bid on your state’s exchange in order to use a new tax credit to buy your own health insurance. While it remains to be seen what the real effects of the overhaul of health care will be, it’s pretty clear that we’re going to wait until after the election to actually experience them.