Managing Your Practice

As the Affordable Care Act comes of age, a look behind the headlines

Author and Disclosure Information


An end to preexisting-condition exclusions and other harmful practices
Insurers offering plans in the state marketplaces also must abide by important insurance reforms:

  • They must eliminate exclusions for preexisting conditions. Insurers cannot deny individuals coverage because they already have a condition that requires medical care, including pregnancy. Before this ACA rule, private insurers often rejected applicants who needed care, as well as those who accessed health care in the past. Insurers regularly denied coverage to women who had had a cesarean delivery or had once been a victim of domestic violence.

  • They cannot charge women more than men for the same coverage. Before the ACA, women seeking health-care coverage often faced higher premiums than men for identical coverage. This made private coverage less affordable for our patients.

  • They cannot impose a 9-month waiting period. (Need I say more?)

  • They must eliminate any annual lifetime limits on coverage. Insurers selling policies in the marketplaces cannot end coverage after a certain dollar amount has been reached, a common practice before the ACA. This change is good news for you and your patients. A patient needing long or expensive care won’t lose coverage when the cost of her care hits an arbitrary ceiling.

  • They cannot rescind coverage unless fraud is proven. Before the ACA, private health insurers would often drop an individual if he or she started racking up high health-care costs. Patients in the middle of expensive cancer treatments, for example, would find themselves suddenly without health insurance. This won’t happen for policies sold in marketplaces unless the patient lied on her enrollment forms or failed to keep up her premium payments.

What these changes mean, in real numbers
These protections are critically important to your ability to care for your patients. Here’s what they mean in real life:

  • Health-care coverage for about 10,000 insured women is no longer subject to an annual lifetime coverage limit.

  • Private insurers can’t drop coverage, a change that will affect about 5.5 million insured women.

  • Insurance companies cannot deny coverage for preexisting conditions, which will help insure about 100,000 women.

Each state marketplace offers four types of plans, the idea being to help people compare policies side by side. All plans sold in the marketplaces must abide by the consumer protections I just reviewed. Each tier is differentiated by the average percentage of an enrollee’s health-care expenses paid by the insurer. The more an enrollee agrees to pay out of pocket, the lower his or her premium.

The tiers are:

  • Bronze – The insurer covers 60% of health-care costs, and the insured covers 40%. This tier offers the cheapest premiums.

  • Silver – The insurer covers 70% of costs.

  • Gold – The insurer covers 80% of costs.

  • Platinum – The insurer covers 90% of costs.

If everything had gone according to plan, women’s access to health insurance would have increased dramatically nationwide, including in the dark blue states in FIGURE 1 (Map 1)—states that rank lowest in access to care. You’ll notice that many of the states that are dark blue in Map 1 shift to light blue in Map 2. Take a careful look at those dark blue states and see what colors they are in the next two maps (FIGURES 1 and 2). Hint: There’s a pattern.

Problem 1 – Strains on
When the ACA was signed into law, most states were expected to build and run their own online marketplaces. The federal government offered to run a state exchange if a state didn’t. Few ACA engineers anticipated that the federal government would have to run the marketplaces in more than half the states—politics-fueled decisions in many states. Now you can see that many of the states that are dark blue in Map 1 are gray in Map 3 (FIGURE 2). Many states whose populations have the greatest need left it to the federal government to run the marketplaces.

Data indicate that state-run marketplaces are doing pretty well—a fact not often caught in frenzied headlines. If we look at the percentage of the target population actually enrolled in marketplace insurance plans during the first month, we see that the lowest state marketplace enrollment was in Washington State, with 30% of its target population enrolled. The highest target-population enrollment was achieved in Connecticut, with 191%.

Compare these numbers to the rates of target-population enrollment in states with marketplaces run by the federal government, which range from 3% to 20% (FIGURE 2). During the first month, federal and state-run marketplaces together enrolled 106,000 individuals into new coverage, 21% of the national target.

Next Article:

The 2014 CPT and Medicare code changes affecting ObGyn practice

Related Articles