Early Diagnoses of the New Law
By THE NEW YORK TIMES, March 29
Love it or hate it, the health care overhaul is the most significant piece of domestic legislation to emerge from Washington in decades. The new law is also ferociously complex: the original Senate bill, which served as the blueprint for most of the changes, ran well over 2,000 pages.
So what is buried in those pages? Here are some thoughts from health care experts on what the changes will mean for Americans, sick and well alike.
Elizabeth A. McGlynn
Associate director of health programs, RAND Corporation.
Can the health care system handle the demands of 30 million-plus new customers?
It’s estimated that more than half of the newly insured will be under age 35, and about 80 percent will be in good to excellent health. They will not be using services for the first time, but they may decide to change providers. More than one-third will enroll in Medicaid, and it’s thought they will use fewer services than those with private insurance.
Still, in the short run, the capacity of the system to meet demand will be strained, particularly in areas that currently have high rates of uninsurance.
Consumers shouldn’t be surprised to find a system in flux as we look for new ways to deliver health care. Patients might see a nurse practitioner instead of a doctor for routine problems; they might confer with their doctor over secure Web sites or their cellphones. We’re likely to see health care delivered in ways we’ve never seen before.
Brian D. Smedley
Vice president and director, Health Policy Institute at the Joint Center for Political and Economic Studies.
The dramatic passage of health care reform was a historic turning point in the effort to repair a deeply broken system. But by itself, the legislation will not be enough to address the needs of many people of color, who face higher rates of infant mortality, chronic disease and disability, and premature death than white Americans do.
The new law will help expand insurance coverage and improve access to health care providers in underserved communities, among other benefits. But the major reasons for the persistence of racial and ethnic health inequalities are socioeconomic inequality and differences in neighborhood living conditions — both of them fueled by residential segregation. These are the issues that policymakers must tackle if we are to improve opportunities for good health for all.
Michael D. Tanner
Senior fellow, Cato Institute.
It’s not just what the bill will do; it’s also what it won’t do.
It won’t do anything to lower premiums. Insurance premiums will roughly double over the next 6 to 10 years for people with group coverage through work, just as they would have without the legislation. For nearly 37 million people in the individual insurance market, the new minimum package of benefits means that they can expect to pay 10 to 13 percent more than they would have if the bill hadn’t passed.
About 57 percent of these workers will receive at least some subsidies to help offset the cost, but 43 percent will have to bear the full cost. True, they will receive more benefits, but it will not be by their choice.
Henry J. Aaron
Senior fellow, Brookings Institution.
Everyone should recognize that there will be no parting of the heavens. Changes in a $2.6 trillion industry will not come quickly. For the immediate future, the number of uninsured will most likely keep on rising. Spending will keep increasing at excessive rates. The quality of care will not be instantly transformed.
But a process of reform that will take a generation to unfold must begin now. And that requires a sustained effort by health reform supporters to explain to the public what is in the bill and to clear away misconceptions created by opponents.
Consumers stand to gain enormously from efficient, well-designed health insurance exchanges. But state officials opposed to reform may well stall and create roadblocks. So supporters should mobilize now to see that as many states as possible move promptly to enact the laws necessary to create these exchanges.
Administrator, Health Care Financing Administration, 1990-92.
Many of the uninsured are going to be unpleasantly surprised that new insurance options for them remain years away — 2014, to be precise.
That’s the year insurers will have to take all applicants regardless of pre-existing conditions. Everyone earning less than 133 percent of the poverty line ($14,404 for a single person) will be eligible for Medicaid. People who aren’t offered employer-sponsored insurance whose income falls between 133 percent and 400 percent of the poverty line, and who aren’t already on a public program, will be offered subsidies to choose among negotiated insurance plans through state-organized insurance exchanges.
Some benefits, primarily for limited groups of individuals, will be available later this year: some young adults will be able to stay on their parents’ plans, and people who have been deemed uninsurable will be able to buy insurance through subsidized high-risk pools. These are not trivial benefits, but they are not relevant to most of the uninsured.
Unlike the benefits, much of the financing starts before 2014. Consumers will feel those effects directly and indirectly. Health insurance premiums are likely to rise, and many seniors who have been on Medicare Advantage plans are going to find their benefits cut or premiums raised, since almost 30 percent of the Medicare cuts come from reductions in payments to these plans. We’ll have to see whether promises of more benefits in the future will outweigh the short-term pain.
Timothy Stoltzfus Jost
Professor, Washington and Lee University School of Law.
Health care reform is now the law of the land. But most of the insurance reforms, including the consumer protections and exchanges, must be implemented by the states. The law asks states to adopt the federal standard or their own equivalent standards. The federal government will enforce the law’s requirements or set up a health exchange only in states that choose not to do so.
This is a real opportunity for the states, and in particular state insurance commissioners, to design approaches that fit their own situations. But there is also a threat to consumers if states adopt laws that do not measure up to the federal standards. It is unfortunate that a quarter of the states have started off on the wrong foot, challenging the law rather than working with it creatively to serve their own citizens’ interests.
Yvette Roubideaux, M.D.
Director, Indian Health Service.
The new health care law will expand the services we provide to American Indians and Alaskan Natives. For example, it authorizes us to provide hospice, assisted-living, long-term and home- and community-based care to these communities, often for the first time. It allows tribes and tribal organizations to buy coverage for their employees from the Federal Employees Health Benefits Program. It will enable us to expand behavioral health programs for Indians.
William H. Dow
Associate professor, University of California, Berkeley.
Expanding health insurance to 32 million more people will greatly strengthen our country’s safety net. The reforms will also improve the health of many of those currently uninsured, addressing a national disgrace: the premature deaths of uninsured people who cannot get medical care.
But inadequate health care accounts for just 10 percent of premature mortality. Even with these reforms, our populationwide health indicators will continue to trail those of other developed countries.
Significant improvements in life expectancy will require turning our attention to underlying social determinants that lead people to fall ill in the first place. The next major social policy fight should concentrate on the single most important factor that research suggests will improve the health of the next generation: investing in the education of disadvantaged youth.
Director of health policy, Center for American Progress.
One of the most important features of the new health care law is the requirement that almost everyone carry health insurance or pay a fine. This may trouble some people, but it is necessary if important reforms strongly supported by most consumers are to work.
These provisions include requiring insurers to cover all people at all times, regardless of health history and without discriminatory pricing. Without the so-called individual mandate, many people who are healthy would decline to buy insurance, knowing that they could purchase it only when they got sick. That would drive up prices for everyone.
President, Commonwealth Fund.
Young adults are likely to feel the most immediate impact of the legislation. They constitute 19 percent of the uninsured, and among those without insurance, two-thirds report problems getting access to care and half report problems with medical bills or debt.
By September, young adults will be allowed to remain on their parents’ health plans up to age 26. And starting in 2014, Medicaid will be available to all adults with income at or below 133 percent of the federal poverty level — 7.1 million uninsured people ages 19 to 29. In addition, they will be able to buy coverage through health insurance exchanges, where two-thirds of young adults (those with incomes below four times the poverty level) will receive help paying premiums and medical bills.
With secure coverage, I think many more adults starting out in life will feel free to follow their dreams rather than the safe road to jobs that offer health benefits.
Jacob S. Hacker
Professor political science, Yale University.
Perhaps the most attractive promise of reform is that if we lack or lose coverage, we’ll have the security of knowing we can buy affordable insurance through the exchanges set up by the states. This promise won’t be effectively realized, however, unless state and federal leaders charged with setting up the exchanges are pressured to keep private insurance premiums in check.
After all, 99 percent of local insurance markets are “highly consolidated,” according to the American Medical Association, and in 24 states (up from 18 a decade ago), the largest insurer has more than 70 percent of the market. At a minimum, strong exchanges will be needed to encourage competition and transparency.
Even better, consumers should demand a public insurance option that would compete with private plans — immediately cutting 10 percent off the average private premium, according to the Congressional Budget Office, and saving the federal government more than $100 billion over 10 years.