The Affordable Care Act Launches Into Reality

The Patient's Bill of Rights becomes the law of the land.



Idaho woke up to another gorgeous Indian summer morning on Sept. 23, and the morning headlines included a story about a local teen being arrested for vandalizing schools, a preview of the upcoming Boise State-Oregon State football game, and an Earth-shattering expose of how Katy Perry was too sexy for Sesame Street.

But much less attention was paid to wholesale changes in our systems of care. The talking heads on major news networks were in high-pitched discourse surrounding the six-month anniversary of the signing of the Affordable Care Act, better known as health-care reform. Wingnuts from both ends of the political spectrum suited up to kick around the political football, labeling health-care reform as everything from a panacea to the very depths of a socialistic hell. Most, however, missed the real game-changer.

The new Patient's Bill of Rights, which is part of the Affordable Care Act, went into effect Sept. 23 and began a new era in how we care for ourselves and one another. According to the new law:

• Patients do not have to pay a copay or deductible to receive preventive health care (mammograms, colonoscopies, immunizations, pre-natal care).

• Insurers can't deny coverage to kids with pre-existing conditions (diabetes, club foot, cleft palate).

• Parents can now keep their children on their insurance plan until age 26.

• Insurers can't cancel your policy without proving fraud.

• Insurers can't put lifetime limits on your benefits.

• Insurers can't deny claims without a chance for appeal.

While there's some fine print, the new rules impact all new policies, and all existing policies will be phased in to compliance gradually.

About an hour after sunrise on Sept. 23, Susan Johnson was already spreading what she called "the good news."

"It's a great day for families and children all across Idaho," beamed Johnson.

BW sat down with Johnson the morning after she tried out her new hobby, flyfishing, on the Boise River. When she's not in waders, Johnson is the Region 10 director for the U.S. Dept. of Health and Human Services. She's the Obama administration's point-person for all matters regarding health-care reform in an area that covers Idaho, Alaska, Oregon and Washington.

"If you think it was all right for a child born with a disease to be denied insurance, then you can pine for the past," Johnson said.

"If you think it was all right that people are lined up on gurneys blocking hallways around emergency rooms because they have no medical home and they've waited too long until things get out of control," Johnson took a deep breath, "well then you can decide that the past was a better deal."

Such sweeping reform in care will require systematic adjustments, and to facilitate those changes, states will receive federal aid. For starters, Idaho will receive $3 million from the Affordable Care Act to build up the primary physician workforce.

"As more people are insured, we're going to need more family doctors," said Dr. Ted Epperly, program director and CEO of the Family Medicine Residency of Idaho. His program will soon receive nearly $2 million to shore up its rural training tracks in Caldwell and Twin Falls.

Epperly said the money couldn't have come at a more opportune moment. While the need for primary care grows, particularly in rural Idaho, the number of family doctors isn't keeping up.

"The funds will allow our Caldwell track to grow by a third and our Magic Valley track to double," said Epperly.

"The front end of the law immediately tries to rectify some of the insurance issues that were devastatingly discriminatory," said Epperly. "But the big piece comes next. We'll expand the pipeline on the types of doctors that we'll need to provide preventative care to more Americans."

But "expanding the pipeline" is where the great divide begins between those who see reform as a lifesaver and those that see it as unconstitutional.

Earlier this year, Idaho joined a 20-state lawsuit against the federal government to halt the new health-care act. By mid-October, a federal judge is expected to rule on a motion from the U.S. Justice Department to dismiss the suit. Idaho Attorney General Lawrence Wasden fully expects the case to make its way to the U.S. Supreme Court.

"I agree that health care in this country needs to be improved, needs to be fixed, needs to be remedied," Wasden told BW. "But the question is really about the system and whether it fits into the confines of the U.S. Constitution. It's a legal issue."

On Sept. 29, a group of Idaho physicians met with Wasden and tried unsuccessfully to convince him to withdraw Idaho from the suit.

Dr. Timothy McHugh, who runs a family medicine practice in Meridian, made the house call along with colleagues Dr. Andrew Wilper, and Dr. William Weppner.

McHugh said: "What struck me as somewhat odd was that Wasden likened the Affordable Care Act to a hypothetical that Congress mandate all citizens wear blue hats. And he asked the question, 'If Congress required that everyone buy blue hats, would you be in here asking me to drop that suit?' And all three of us doctors were of a like mind that if buying a blue hat would save the lives of 45,000 people who die each year due to lack of health care, then absolutely! We'd be first in line to buy those blue hats."

"But he assured us that in no way does his lawsuit impede the implementation of the law," said McHugh.

Wasden reiterated: "The federal legislation is now the law of the land, and all those processes need to move forward."

One block away from Wasden's office at the Idaho Department of Insurance, those processes have landed on the desk of Bill Deal. Having worked in the insurance industry for nearly a half century, Deal now oversees the Department of Insurance as its director.

"It's a new time. It's the law of the land," Deal echoed. "And we have to interpret the changes as best we can."

Deal has three constituencies: Idaho citizens, some 74,000 producers or agents (10,000 are Idaho residents) and the roughly 1,600 insurance companies doing business in Idaho (only about 19 are headquartered here).

When it comes to health insurance, that pool gets pretty shallow. There are only seven carriers who offer individual health-care coverage, and two of them--Regence Blue Shield and Blue Cross--hold the lion's share of the lambs.

Regence Blue Shield controls 30 percent of the Idaho market with premiums of more than $100 million. Blue Cross is second with 23 percent of the market and premiums nearing $78 million.

Deal said the companies' success in Idaho is due to administrative efficiency and competitive rates.

"Idaho has the lowest rates in the nation," Deal said. "Out of 50 states, according to the Internal Revenue Service, Idaho has the lowest group rates for health insurance in the United States. And for individual rates, we're about 47th in the nation."

Deal clearly has a sense of how reform will impact those rates.

"Take away exclusions for pre-existing conditions. Uncap the lifetime benefit. Add new essential coverages and well-care," Deal itemized. "As a result, you'll have a more benefit-rich package. You can certainly expect a rate redistribution."

But not everyone is convinced that rates will shoot up.

Dr. Julie Welty is a family physician in McCall. She serves a part of Idaho that has seen the longest and darkest shadows of unemployment and poverty, and when she talks to her friends and colleagues who might be a bit more conservative, she reminds them that reform makes good business sense.

"So many people come into our emergency rooms that have no coverage. And of course we have to treat them," argued Welty. "We're, more often than not, treating them for problems that could have been prevented. And we're all paying for that. It ends up in your insurance rates. It ends up in your taxes."

And Welty's strongest sentiments surround preventive care.

"We're talking about a colonoscopy long before colon cancer. A pap smear before cervical cancer. A mammogram long before someone could die from breast cancer," she said.

Welty comes from a family of healers. Both her father and mother are physicians. Dr. Thomas Welty and his wife, Dr. Edith Welty, spent a quarter century serving the impoverished on Native American reservations for the Navajo and Sioux. In addition, for the last decade, they've been traveling once or twice a year to Cameroon in West Africa.

"We feel empathetic toward people that we know could benefit from systems of care but can't access them, purely based on cost," said Dr. Thomas Welty.

"This lawsuit against the Obama administration is counterproductive," said Dr. Edith Welty. "It's so much better to just look at the new law and see how it can be best used to help Idahoans."

That's why Dr. Welty ... and Dr. Welty ... and Dr. Welty all signed a harsh letter to Wasden.

The letter included the following passage:

"Your attempt to block the requirement to purchase insurance and the expansion of Medicaid threatens to harm our most vulnerable patients in Idaho that cannot afford health insurance or are being denied coverage. The lawsuit leaves uncertainty for families that desperately need access to health care."

After the letter was sent to the media, including BW, Wasden said he was more than happy to meet with the group.

"I explained to them that legal issues are at stake. It's not about policy," said Wasden. "We've had conversations with a lot of folks on this issue. Anecdotally, I can tell you that the majority of people who have called our office are, by far, supporting our lawsuit."

When HHS Regional Director Johnson visited Idaho, she told BW that she hoped Wasden would "slow down and take a deep breath before proceeding."

When BW asked Wasden to comment, he chuckled.

"Coming from you, that's hearsay. But I'd be more than happy to meet with her in person."

Meanwhile, the lawsuit moves forward. But so does sweeping reform.

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