EDITOR’S NOTE: This is the second of a three-part series from journalist Arlene Karidis, whose career as a health reporter spans two decades. Karidis says the Affordable Care Act is already helping many of the people who need it most, but that for many more Americans, the best of the reform legislation is yet to come.
Jennifer, a 33-year-old college student, struggles with mental illness. It’s been an ongoing battle for Jennifer, who’s founder of a nonprofit organization for cancer survivors. Fortunately, health reform has enabled her to breathe some relief.
One of the biggest weights off Jennifer’s shoulders is that she is no longer up against a lifetime limit for hospitalization. “Previously I was discharged from the hospital before I should have been because of the lifetime limit, which for me was $50,000. That’s the cost of about three admissions,” she says. “Fortunately I haven’t required inpatient care for some time, but knowing it will be there should I need it, is a relief.”
While the federal law mandates that group plans cover behavioral health at the same level as medical and surgical benefits, compliance can be spotty. Organizations such as the National Council for Community Behavioral Healthcare continue to advocate for broader education and compliance in this health care niche.
But at least as of 2010, the health reform law provides a mechanism to appeal a coverage determination, regardless of an individual’s health issues. The new external review process for consumers is expected to be critical for anyone requiring ongoing, expensive health care, and who may have a claim denied by their insurance carrier. Because the provision is new, its effectiveness remains to be seen, but people like Jennifer and her husband, Jason – who suffers from chronic asthma – see this as a move in the right direction.
The couple are eagerly awaiting a provision banning denial of coverage based on pre-existing conditions. Jason has worked for UPS and had insurance with his employer for 17 years, but has been denied coverage of his asthma because he was diagnosed as a child. “Often, when he tells a doctor he has insurance – but it won’t cover asthma – they require 100 of payment up front, and Jason has gone without care because we just couldn’t afford it,” says Jennifer.
The two – and others in their situation – can also look forward to cost-lowering health reform provisions that take effect in 2014. One provision is Medicaid expansion that will cover individuals at 133 percent of the poverty level and below. For moderate-income individuals – above 133 percent of poverty but below 400 percent – state-based health insurance exchanges will provide tax credits to help pay for premiums. The lower costs will be critical for those living with chronic conditions.
“With mental illness, the lower premiums will be significant because the people affected tend to have multiple morbidities,” says Andrew Sperling, Federal Legislative Advocacy Director for the National Alliance on Mental Illness (NAMI). “No longer will they be denied or priced out of the market because they have bipolar disorder or schizophrenia and also have diabetes or chronic obstructive pulmonary disease. Once full-blown health reform kicks in, their situation will be radically different.”