Sunday, April 29, 2012

Strong Industry Oversight Key to Healthcare Overhaul's Success

CareShare Network cannot say whether the new healthcare law is the antidote for the US’ healthcare woes. However, we hope the system will provide recourse for individuals with ongoing medical conditions when they are in conflict with their insurers over their care. 

In 2007, the CareShare Network blog featured the story of a woman who had appeared on Good Morning America.  She was living with a rare condition. In spite of her personal entreaties and letters of support from her doctors, her insurance provider would not cover the only medication capable of helping her.

Even with Good Morning America’s national spotlight on its policies, the insurer stood firm unwilling to reverse its decision. The woman was frustrated and baffled that one entity could hold such power over her life and health.  

In cases where doctors recommend one treatment and the insurer denies coverage, under the new law, will a strong third party oversee the appeals process?

Currently, a version of this arbitration process exists.  When private insurers make a decision patients believe is wrong, patients have the right to appeal.  Unfortunately, an appeal often ends in insurers affirming their own decisions:  The insurer claims their internal, impartial medical teams further reviewed its decision -- and approves of it.

These reviews can go as far as a state appeal board.  Some patients follow the process through its end at the state level. Others give up, exhausted and depleted at the thought of facing yet another battle with an uncertain outcome.

Our reason for recounting this story of old is to stress the need for an official, independent and strong appeal system implemented to protect patient consumers under the healthcare law. Otherwise, the national insurance mandate becomes a boon for private insurers, leaving consumers trapped between accepting inadequate private plans and no viable alternative when they fail them.

Healthcare Reform Law Overview

What to think and what to do?  As the nation awaits the Supreme Court’s decision on the Affordable Care Act, the healthcare reform bill passed by Congress and signed into law by Pres. Obama on March 23, 2010, CareShare Network looks at what’s at stake in the challenges to the law.  We also take a look at the changes the law will implement.

According to the New York Times in “Health Care Reform  and the Supreme Court (Affordable Care Act),” the challenges to the healthcare law hinge primarily on the individual health insurance mandate, which will require US residents to either purchase coverage or pay a penalty.  Assessments for penalties will begin in 2014 to be paid through 2015 tax returns. The government argues that the compulsory component of the law must stand because insurers will only provide coverage to all applicants without regard for preexisting medical conditions because of the mandate. 

The Supreme Court is addressing three other questions:
  1. Should the court wait for the penalty to be levied in 2014 and paid in 2015 before considering any lawsuits?
  2. What other parts of the law should be upheld or discarded if the Court strikes down the mandate?
  3. Can the federal government require the states to expand their Medicaid rolls by raising the eligibility thresholds in order to offer health insurance coverage to more low-income families?     
With the aim of providing coverage access to the 49 million US residents without health insurance coverage at all, the law will also assess a penalty on large employers that do not offer health insurance and provide tax credits to smaller ones, compelling or incentivizing them into coverage provision for their employees.

It also creates health exchanges for individuals who must purchase policies in the individual market. The exchanges will provide information on private insurance options.  Some individuals will receive subsidies based on their income levels to purchase policies available in the individual market through the exchanges.