General Discussion
In reply to the discussion: I wish people wouldn't be so rude to those who lose out under the ACA. [View all]StrayKat
(570 posts)ACA coverage is not as complete or protective as advertised. A small sampling of the areas that to me represent spotty coverage and care not addressed or not properly addressed by the ACA:
ACA Gaps and Loopholes
The area that the ACA has focused on the most is limiting the cost of health insurance. The subsidies are good as is the removal of lifetime caps, but there are still gaps and loopholes. One of the worst gaps is the Medicaid Gap. The ACA was written so that subsidies would start for those whose income is 133% of the poverty line. However, Medicaid is generally only offered to those below the poverty line or with some extenuating circumstances like kidney transplants. The federal government required states to extend Medicaid to those in the 100% to 133% of poverty range. The feds would fully reimburse the increased cost for the first several years. Some states complied, but some didn't and took it to the Supreme Court, which sided with the resistant states. This leaves people who really can't afford to pay a premiums in the lurch. They don't qualify for Medicaid and they don't qualify for subsidies.
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Have you seen the variation of the cost of various procedures? Within the same city the cost of being on a ventilator was $115,000 at one hospital and $53,000 at another. How can this not influence who gets which procedures? Medicare and Medicaid dictate prices, but for the rest of us the sky's the limit, and justification is not required.
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There are also loopholes in the ACA that allow for astronomical additional charges to premiums for some procedures. One of the big ones here is gastric bypass. As an example, one catastrophic plan here covers gastric bypass costs $1,320/month for a single person under 50. The same gold level plan for a family costs nearly $5,000/month. Traditional diabetes treatment is covered under the lower cost plans (at 10 - 25% of the cost), but not the gastric bypass. Yet, bypass surgery has been shown to be more effective than medication at combating diabetes, and at least one study found that a gastric bypass procedure and follow-up care tends to cost the insurance company less than a lifetime of diabetes treatment. Further, as mentioned in the same study:
Studies from European countries with nationalized health care systems have found that bariatric surgery is cost-effective from a 5-year societal perspective. . .
But, the cost of the bypass plans is so exorbitant that it poses a major financial obstacle to many, and would likely influence which treatment option is chosen. This is a form of spotty coverage created by wealth inequality issues the ACA doesn't address.
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Some people seem to be insisting that the ACA will mean that needs like prescription drug and maternity coverage are necessarily provided by all Exchange plans. This actually assumes that people are getting bronze, silver, gold, or platinum care. But, there is also catastrophic care, which does not cover these. So, some people paying into the system still won't be covered for basics. Remember that expensive gastric bypass plan? It doesn't cover the cost of diabetes meds. In the summary of benefits it estimates on p.7 that it would pay $50 out of $5,400 in treatment costs with $2,900 of that being prescription costs for type 2 diabetes.
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The ACA also doesn't do much to protect against the completely independent everyday shenanigans that the insurance companies got up to prior to enactment and will continue to get up to until there is real reform.
I'll use a local example of a service 'outage'. Kaiser Permanente has been in a long-time feud with area hospitals, and this year finally severed ties with them for reasons totally independent of the ACA. Kaiser insures about 500,000 people in the county and there are four hospitals, but now there is only one that Kaiser patients can use for non-emergency surgeries and procedures. This is a huge change. The three hospitals that no longer participate with Kaiser have 1,333 beds combined while the one remaining participating county hospital has 187 beds. Additionally, the one remaining participating hospital has the worst ratings of the 4 county hospitals.
Although the ACA did not spur this change, it does nothing to protect against it. A universal healthcare system would.
There are many more ways in which coverage and care are still spotty under the ACA. . .