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The Affordable Care Act from an oncology social work perspective: What’s in it for Patients and families?

by Sarah Conning, LCSW, OSW-C; Association of Oncology Social Workers

After tumultuous public debate, the Patient Protection and Affordable Care Act (ACA) became law in March 2010. Nearly two years later, the law is still in the throes of political controversy and legal challenges. In the face of such monumental changes, complicated timelines, legal uncertainties, and small print, what is a social worker to do?

Oncology social workers can serve our patients by being well-informed about the key provisions of the law and aware of the basic timeline for changes. With some basic information and access to quality resources, we can be the go-to people in our respective settings for accurate and unbiased information to serve our patients.

The law includes provisions to expand coverage, control health care costs, and improve health care delivery. It is designed to be implemented gradually, so some provisions are now in place while others will be implemented in the coming months and years. If the law stays intact, the biggest changes will come in 2014.

There are excellent resources we can all use to learn more about the ACA. Here are some great places to start:

The federal government web portals: www.HealthCare.gov, which offers information about the full range of benefits offered through the ACA and www.PCIP.gov, for information about pre-existing condition insurance plans.

Kaiser Family Foundation video “Healthcare Reform Hits Main Street” (9 minutes), as well as informative timelines, summaries, and in-depth explanations available at http://healthreform.kff.org/.Cancer Legal Resource Center, The HCP Manual: a Legal Resource Guide for Oncology Health Care Professionals; 3rd Edition, 2012. I encourage all oncology social workers to keep this manual on their desks. See http://www.CancerLegalResourceCenter.org or call 866-843-2572.

Where we are right now

Though the biggest changes are yet to come, some provisions are now in place that expand health insurance options for our patients:

  • Young adults can remain covered under a parent’s health plan up to age 26.
  • Individual and group health plans cannot deny coverage to children under age 19 based on a pre-existing condition.
  • An early retiree reinsurance program allocates federal money to help companies continue providing health coverage for early retirees age 55 to 65.
  • U.S. citizens and legal residents who are unable to obtain health insurance in the private market due to a pre-existing condition, and have been uninsured for six months or more, can purchase insurance through their state’s pre-existing condition insurance plan (see www.pcip.gov). This is a stop-gap measure until guaranteed issue provisions go into effect in 2014. (Note: Pricing will vary by state and premium subsidies will not be available until 2014.)
  • States have the option to provide Medicaid to childless adults with incomes up to 133% of the federal poverty level, regardless of disability. Connecticut, the District of Columbia, and Minnesota have begun providing this coverage.
  • The healthcare.gov website offers  assistance in identifying health coverage options, in both English and Spanish.

Other ACA provisions provide consumer protections for those with commercial insurance plans (note: some  provisions do not apply to self-funded plans or “grandfathered plans” issued before September 23, 2010):

  • Individual and group health plans cannot place lifetime limits on coverage.
  • Individual and group health plans are restricted in the use of annual dollar limits on coverage for “essential health benefits”; starting in 2014 annual limits will not be permitted.
  • Individual and group health plans cannot rescind coverage, except in cases of fraud.
  • New health plans must have effective processes in place for appealing decisions and for external review.
  • New health plans are required to cover defined preventive services without cost sharing (i.e., no deductible or co-pay). This includes mammograms, BRCA counseling about genetic testing, colorectal cancer screening, tobacco cessation interventions, and more.

The law has created some welcomed changes in Medicare:

  • Patients with Medicare Part D insurance who reach the coverage gap (or “donut hole”) now automatically receive a 50% discount on brand name drugs and a 14% discount on generic drugs. These discounts will gradually increase until the coverage gap is closed in 2020. The entire price (without discount) is counted toward the amount required to receive catastrophic coverage.
  • Cost-sharing for Medicare-covered defined preventive services has been eliminated.

Much more to come

Starting in 2014, the law requires U.S. citizens and legal residents to have qualifying health coverage or pay a tax penalty. This provision, known as the “individual mandate,” is the most controversial component of the ACA and was  the subject of intense debate before the  Supreme Court last week. A decision on the constitutionality of the ACA is expected in June. The law expands health insurance coverage, regardless of pre-existing condition, through several mechanisms:

  • Employers: The law creates incentives and penalties designed to maintain employer-based insurance for most workers.
  • State-based Exchanges: Individuals without employer coverage and some small businesses  will be able to purchase private insurance, regardless of pre-existing condition, through their state’s insurance exchange. Insurance companies will not be able to take pre-existing conditions or gender into consideration when establishing premiums. Federal subsidies will help cover the cost of purchasing health insurance policies on the exchange, for those with income up to 400% of the federal poverty level.
  • Medicaid: State Medicaid programs will expand to cover all individuals with incomes up to 133% of the federal poverty level.
  • Medicare: Medicare will continue to cover those age 65 and older and the long-term disabled.

Also of note for oncology social workers, starting in 2014 health plans cannot deny participation in a clinical trial and must cover the “routine patient costs” for services furnished in connection with the clinical trial.

The law also contains provisions designed to control health care costs and improve quality, which have the potential to change the environments in which social workers practice. For example, a new Center for Medicare and Medicaid Innovation (http://innovations.cms.gov) was created to explore new models to provide better health care at reduced cost. Social workers would do well to stay abreast of these new approaches, such as “Accountable Care Organizations” (ACOs) and “the patient-centered medical home,” and continue to voice the essential skills that our profession brings to the health care system.

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