The Reform Dummy

Health Care Reform For Dummies… By A Dummy

Improvements in Healthcare Coverage for all Americans

America: The land of the intimidated and the home of the lazy.  Between politics and media, we’ve all gone cross-eyed over what is and what isn’t.  Divide and conquer; it’s the oldest trick in the book.  Nevermind the facts, listen to my voice and believe my opinion.  It’s the American Way…

The Healthcare Bill is now the law of the land.  As Bill Maher said, “I never thought I’d see the day when Americans could buy health insurance from the insurance companies.”  The propaganda campaigns have been relentless on both sides.  And while a government-takeover, this is not; it also isn’t the sweeping overhaul that will change our lives forever.  But yes, Joe Biden, it is a Big Fucking Deal.  

Although certain parts won’t go into effect for some time, it is of great importance to understand what this new legislation entails for us all.  Everyone’s fingers have been in the misinformation pie.  Teabaggers, Carpetbaggers, Coffee Grinders, liberals, conservatives, and even those crazy fucks down in Congress have been trying to convince you of what this law will or will not do.  Do I have to go to the DMV for my check-ups?  Are illegal immigrants covered?   Will it provide for my teenage daughter’s abortion?  Well, why not read the fine print and find out for yourself?  More than likely, it’s because you haven’t the time nor the patience to sit through 2,076 pages of “What the Hell Does THAT Mean?!”  Not even the weasels on Capitol Hill have time to read before they vote.  The shit flows downriver.  They hire some pimple-faced college kid to read it and report their meager understanding.  But, little Josh is too busy avoiding tickle fights to get any reading done over in Washington.  So that leaves you poor, unfortunate saps with me, The Reform Dummy, and the most epic book report of all time…

Bill H.R. 3590, otherwise known as The Patient Protection and Affordable Care Act, passed in the House of Representatives on March 21st, 2010.  It was signed into law by President Obama two days later.  A reconciliation bill (which I will also feature) has subsequently been passed in an effort to trim out the more frivolous earmarks (those shady deals benefiting only one state/district in order to rack up the Yes votes).  My goal here is to read all of this legislation and provide my understanding of its contents.  Feel free to comment, ask questions, read along with the bill and correct me where ever you feel necessary.  Please keep in mind that I am in no way involved in the insurance or health care industries, and I am not a politician.  I’m just your average American dummy and any accuracy in my depiction of this law is purely coincidental.

The initial subsection is in regard to Health Insurance Reform.  It does not yet get into the Public Option.  This is simply a set of new regulations being put on the insurance industry in an effort to protect people from corporate greed.  In this chapter, we cover:

  •         Limits
  •         Coverage Protection
  •         Consumer Protection
  •         Co-Pays (or lack, thereof.)
  •         Wellness Promotion
  •         Grants/Funding
  •         And More!

Title I: Quality Affordable Health Care for all Americans

Subtitle A: Immediate Improvements in Health Care Coverage for All Americans

There will be no more lifetime limits on the dollar value of your policy, and no unreasonable annual limits.  So feel free to run up that tab because Kaiser’s footing the bill.  Insurance companies can no longer cut you off just for being sickly.  However, caps on particular benefits are permitted where already allowed by state or federal law (there’s always a catch).  And, down the line, there may be provisions created for value-based plans, which sounds like a Pay-As-You-Go program to me.

Although it is believed that the removal of limits will lead to sky rocketed premium payments, The Secretary of Health and Human Services is required to conduct annual reports on premium increases to regulate any unreasonable spikes in rates.  That’s not to say Madam Secretary’s investigations will fully protect the American people, but that is the idea. 

The long practiced pastime of rescinding coverage from insured individuals in their time of need has now become outlawed.  Except in cases of fraud and misrepresentation, coverage cannot be terminated.   And prior notice must always be given.  So if you get sick, if you get cancer, if your big toe nail falls off and it looks really gross… your provider can’t turn around and say “oh that’s too bad, if only you were covered by some sort of program that took care of you in these instances of misfortune.”  They also have to provide a reasonable appeals process when claims are denied.    

Furthermore, within one year of this law going into effect, all insurers have to provide the insured with a clear cut summary of their benefits and coverage; uniform, no longer than 4 pages, no smaller than 12 point font (no fine print here!), and in language your typical American can understand – with definitions.  And the insured must be notified of all modifications to their plan at least 60 days prior to their initial affectivity.  Failure to comply results in a $1,000 slap on the wrist  – Of course they also have to tell you that the summary is not your actual contract. If you want the details you need to get out your magnifying glass and hit the books.

Let us rejoice! There are no more co-pays for checkups!  The following items must now be covered by insurance companies… FULLY:

**There is an interesting paragraph following that bit about no co-pays.  A required “interval” is provided for, between the time a recommendation for these items/services is issued, and the effective date of your policy.  What I think it means is that your policy has to be effective for a year before the recommendation can be issued.  …Is that right?  Can that be?  Are there any insurance people in the audience?  It’s on page 18 of The Bill, if you check my link at the top.  Somebody please get at me about this. Thank you kindly.

The sponsor (boss) of a group plan cannot discriminate based on salary.  Employers can’t determine coverage eligibility based on hourly or annual income.  Health care isn’t something you give to the executives as a bonus.  However, if employees are buying into their insurance plan, the sponsor can ask for a lower dollar or percentage amount from those making less money. 

It looks like the industry is going to have to start reporting its efforts to better people’s health (or at least put some actual effort into it).   They have to show reports on quality, case management, care coordination, chronic disease management, and medication and care compliance initiatives.  Now I’m not going to pretend to know what those things “are,” but I certainly feel good knowing someone’s being held accountable for them.  What I do understand is that action has to be taken (by regulation) to prevent hospital readmission after a patient has been discharged.  At least have the decency to put a bottle of morphine in my hand before you send me home with the gash in my forehead half-bandaged and still bleeding.  Face planting into a sidewalk hurts no matter how drunk you are, and it’s going to take more than the Advil PM to quell my cries.  Seriously though, if you’re well, that has to be ensured before they can kick you to the curb.  In addition, steps must be implemented to improve patient safety and reduce medical errors such as amputating the wrong foot or leaving your wristwatch in my chest cavity after surgery.  Reports on all of these requirements have to be submitted to you during open enrollment periods so you can know how fucked you are before you fork over your money.

We have some well defined wellness and preventative measures being enacted:

  1. Stop Smoking
  2. Weight Management
  3. Stress Management (legalize it!)
  4. Physical Fitness
  5. Nutrition (Did you know Carl’s Jr. sells salads now?!)
  6. Heart Disease Prevention
  7. Healthy Lifestyle Support
  8. Diabetes Prevention

Congress will be checking back on your progress in a couple of years, so be ready for beach season 2012, America.

This part, I have to provide an excerpt so you can see what I’m talking about:

“A health insurance issuer offering group or individual health insurance coverage shall, with respect to each plan year, provide an annual rebate to each enrollee under such coverage, on a pro rata basis, in an amount that is equal to the amount by which premium revenue expended by the issuer on activities described in subsection (a) (3) exceeds.”

It sounds like we get a rebate if the amount we pay for our premium is less than the amount we end up using in health care services.  Wouldn’t that just be incredible?  “You only visited the doctor once this year?  Well, here is the rest of your money back.”  Honestly, I feel like I should be wrong here.  Nay, I must be wrong.  And if I’m not, The Bill does go on to say this subsection has no effect after December 31st, 2013.  So don’t get your hopes up.  Again, talk to me, because I’m willing to learn.

Every hospital in America has to provide a list of standard charges for items and services.  This way you won’t have to wonder where all the zeros on your bill came from when it arrives in the mail.

Specific grants will be supplied to states in order to create agencies for health insurance consumer assistance.  These agencies will:

  •          Educate consumers on their rights
  •          Help file complaints
  •          Collect and track problems/inquiries
  •          Aid in the enrollment process
  •          Resolve issues collecting premium tax credits

$30 million is appropriated from the treasury for this in the first fiscal year.  Each subsequent year must be reviewed and allocated by the Secretary of Health and Human Services.  Another $250 million is to be provided to states to carry out the rest of the requirements that have already been set forth.  Each state receiving a grant will get between 1 and 5 million dollars.  So far that’s a drop in the bucket compared to the other things we spend taxpayer money on in this country.

OK.  Let’s all breathe for a moment.  Somehow we’ve managed to cover all the major points in Subtitle A of our new Health Care Law.  Exciting, wasn’t it?  This was my maiden attempt at serious blogging, as well as my first time explaining something so over my head to people just as confused as myself (no offense).  I’ve condensed 41 pages down to about 3, while taking an extremely complex set of regulations and reform and turning it into simple and possibly inaccurate ideas. 

I invite you to please drop some feedback, regardless of whether it’s positive or negative… don’t worry, I can take it.  I want to continue to improve this space and its contents for everyone’s educational pleasures, including my own.  Tune in for my next entry which will cover the expansion of insurance coverage to the currently uninsured (and uninsurable) under Subtitle B.  That’s a pretty important topic considering there’s an estimated 32 million Americans who will be covered until this section. 

Cheers to your health!

-The Reform Dummy


April 2, 2010 - Posted by | Health Care, Patient Protection and Affordable Care Act, Politics | , , , , , , , , , , , , , , , , , , ,


  1. Cool bean jokes bruh keep up the g work

    Comment by Mark G | April 2, 2010 | Reply

  2. cant wait for the next one! you make me so proud

    Comment by Danielle | April 7, 2010 | Reply

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