The New Health Care Reform Law: What Patients Need to Know

The United States has just come through a very contentious round of mid-term elections. During many of the candidates’ ads and debates, much was said about the Patient Protection and Affordable Care Act (PPACA) signed into law in March 2010 by President Obama. Some of what was said was true, some false, and some very misleading.

As ambulatory care nurses, we need to be aware that many of our patients just do not know what to believe about health care reform. They may have no idea what benefits they may receive and in many cases, they don’t know how to access the benefits. They are also concerned, given what was said during the campaign, that the U.S. cannot afford health care reform. One reliable Web site available to check on information promulgated about health care reform is FactCheck.org, a project of the Annenberg Public Policy Center that monitors the media and aims to clear up misconceptions about U.S. politics.

What is true is that we cannot afford health care as it was prior to enactment of PPACA; insurance increases each year have become greater than increases in wages for those who have insurance through work. The U.S. spends more than 16% of its Gross Domestic Product (GDP) on health care, while most industrialized countries (England, Germany, Japan, Taiwan, and Switzerland) spend less than 10% of GDP on health care (World Health Organization [WHO], 2000). There is an excellent PBS program, “Sick Around the World” that highlights these issues.

The cost of health care adds to the cost of producing products and, thus, U.S. products are more expensive and less competitive on the world market. In addition, although the U.S. spends more on health care, it has much poorer outcomes than other industrialized countries that spend much less. According to a WHO Report (2000), the U.S. ranks 37th in health care quality in the world. The WHO report rates national health care performance according to five criteria: Life expectancies, inequalities in health, the responsiveness of the system in providing diagnosis and treatment, inequalities in responsiveness, and how fairly systems are financed.

A primary responsibility of ambulatory care nurses is to raise patients’ consciousness about the options provided by PPACA and increase their understanding of how to access those options. The health care reform law has three main foci:

  1. Health insurance reform
  2. Health promotion, wellness, and prevention of disease
  3. Enhancing access to safe, quality health care

There is an excellent overview of PPACA in the five-minute video, “How Health Care Reform Really Works” designed for consumers by Ellen-Marie Whelan, NP, PhD, the Senior Health Policy Analyst and Associate Director of Health Policy at the Center for American Progress. Dr. Whelan explains very simply how the recently passed health care reform bill will give Americans better care and reduce the deficit.

Other Web sites also offer consumer information. The Consumer Reports site offers a consumer’s guide to health care reform and a health care blog. The American Nurses Association site offers both a timeline for implementation of the health care reform law (Acrobat) and information on how the health care reform law benefits consumers (Acrobat).

In a recent blog post, Kathleen Sebellius (2010), Secretary of Health and Human Services, says that although increases in health care costs are “partly due to rising medical costs and utilization of services, they are also due to rising insurance company administrative costs, including marketing and salaries of CEOs.” She goes on to say that the “administrative costs contribute little or nothing to the care of patients and the health of consumers” and are the reasons for the insurance reforms in the health care reform act. PPACA will require insurance companies to spend 80-85% of premiums on actual health care services and quality improvement activities rather than on overhead.

Sebellius (2010) states:

Any insurer that does NOT spend 80-85% on actual health care services and quality improvement activities will also have to give plan members a rebate based on their excess spending in administrative costs.

Here’s an example of how this would work. Today the average insurance plan for a family of four from a small employer costs $13,250 per year. Under the new rules, insurers would have to spend between $10,600 and $13,250 of that premium on health care and quality. In today’s market, some insurers report spending as little as 60% of premium dollars on care. Under these rules, unless those plans change their spending habits, they would have to refund nearly $3,500 to each family they insure (para 4-5).

Created under PPACA, the HealthCare.gov Web site was launched July 1, 2010, and is the first site of its kind to present information about private and public health insurance coverage options in one place to make it easy for patients/consumers to learn about and compare their insurance choices. Although there are easily accessible Web sites with information on benefits and access to health care insurance and health care, there has not been a consumer-focused campaign that is designed to reach all potential health care consumers in the U.S. According to a HealthCare.gov Fact Sheet, the site and its Insurance Finder tool “are critical new tools for consumers, making the health insurance market more transparent than it has ever been” (HealthCare.gov, 2010). The Insurance Finder tool provides “price estimates for private insurance policies for individuals and families, allowing consumers to easily compare health insurance plans – putting consumers, not their insurance companies, in charge and taking much of the guesswork and confusion out of buying insurance” (HealthCare.gov, 2010).

Much of the Democratic Party’s campaign regarding health care reform was funded and occurred prior to passage of the health care reform act. Much of the Republican campaigning during the midterm elections was funded and focused on negative aspects of the health care reform law. And now, newly elected Republican leadership in the House of Representatives say they will repeal the PPACA. This would be very hard to do given that the Government Accounting Office (GAO) determined that PPACA would decrease health care spending over the next ten years and any replacement for PPACA proposed and voted in by the new Congress would have to have the same savings within it. Also, President Obama has veto power over any new health care bill that does not meet the U.S. needs for access and quality at a reasonable cost.

The real current danger is that the new Congress could also under-fund or not fund mandates within PPACA. Such lack of funding would undermine all or many of the reforms in PPACA such as prevention and wellness and support of expansion of the health care workforce in the area of primary care.

Now is the time for ambulatory care nurses to better understand the health care reform law so that we can help patients and their families better understand it and take advantage of access through insurance reform and programs, especially wellness and prevention offerings.


Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at shaas@luc.edu

References
HealthCare.gov. (2010). HealthCare.gov Insurance Finder gets better for consumers. HealthCare.gov Newsroom.
Retrieved from http://www.healthcare.gov/news/factsheets/insurance_finder_gets _better.html

Sebelius, K. (2010). More value for your dollar. HealthCare.gov Health Care Notes.
Retrieved from http://www.healthcare.gov/news/blog/medical_loss_ratio.html

World Health Organization. (2000). World Health Organization assesses the world’s health systems.
The world health report 2000 press kit. Retrieved from http://www.who.int/whr/2000/media_centre/press_release/en/index.html