Reflections on ACA Implementation: We Must Do Better

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You might have heard President Obama use the phrase, “health care is a human right.” in recent days to demonstrate his argument against defunding Health Care Reform.  Even though this less-than-perfect Health Care Reform begins today in spite of the government shutdown, what really grates is to hear this phrase being used now, when the very value of health care as a human right was ignored the President and the other architects of the Affordable Care Act when they threw out single-payer health care (an option for really nobody to go without health care) as a viable option for the people of the United States. 

While the single-payer health care movement does push on, continuing our 100+ year journey, what we are left with in the Affordable Care Act (ACA) will be implemented today, October 1^st, 2013. 

As I mentioned earlier, the law is certainly less-than-perfect, especially because all it essentially does is increase profits for morally bankrupt health insurance companies.  However, since we are moving forward, I’ve looked a bit more into the details of the ACA, and realized there are actually some pretty exciting things packed in which are worth discussing.

The first to me is this whole “no pre-existing conditions” piece.  As you may know, if you’ve ever looked into purchasing health insurance yourself, a middle-aged person who has diabetes would have been more likely to be denied coverage (or charged much, much more) than a young, healthy 20-something.  In a similar vein, there used to be caps/limits on how much insurance companies would cover services/medicines for people with chronic conditions that the companies feel are too expensive to cover – like cancer, heart disease, diabetes, hemophilia, mental illness. Seems a little counter-intuitive if we’re really trying to protect the sick (that rely on this continued care), no?   Anyways, that is all actually gone now.  Under the ACA, insurance companies that participate in the health care exchanges must only use age, where you live, and whether or not you smoke to determine health insurance prices.  They also cannot deny or charge exorbitant rates to those who have a “pre-existing condition” like this.   

Finally, again on a related note, health insurance companies in the Exchange cannot charge a “co pay” for preventive services like mammograms, colon cancer screening, glucose testing, etc. This is huge news for the South Asian community, where we are 7 times more likely to have diabetes than others in the US, and cardiovascular health, HIV/AIDS, breast and cervical cancer screening rates remain too low, mostly due to an inability to pay/lack of insurance coverage for these preventive services.

It’s actually embarrassing that this advancement is only coming now, but picking up on the thread of “pre-existing conditions,” guess what isn’t a pre-existing condition anymore under the ACA?  Being a WOMAN.  Yup, us women of “child bearing age” would routinely and very expectably be charged a higher monthly premium than men, all other things equal.  While I suspect we’ll get no more than a “big whoop” from eco-feminists like Vandana Shiva for this ‘advancement,’ hey, we’re moving forward!  Yay.   So, women cannot be charged more than men.  And of course, since our primary function continues to be defined by society as baby-makers -- insurance companies have to cover maternity care and breast-feeding supplies.  Now, if we could only get insurance companies to have to cover the cost of other crucial things women need – such as interpretation services and translated notices, sex reassignment surgery, and care for our immigrant sisters who have been in the country less than 5 years or are undocumented.

Since I mentioned interpretation and translation in the last paragraph, let me also acknowledge that it is a great thing that the ACA actually mentions cultural and linguistic competence, something many of us have jumped up and down about for years, in a few different areas – including providing funding for cultural competence training, and, excitingly, community health navigators.   However, we have yet to see how this will all shake out – will all states’ health care exchanges follow NY’s example and reimburse providers for the cost of interpretation and translation?  That is the only way (sadly) to get medical providers to really expand this life-sustaining service.  Will there be standards issued/incentives provided for bilingual health navigators for immigrant communities?   Will they actually lower the required threshold before having to translate health insurance notices (which, admittedly, are hard to understand as a native English speaker) to a more realistic level (currently, 25% of the enrollees need to speak the same non-English language in order for the company to translate their appeals notices into that language)?  

Also, since I mentioned immigrants in the paragraph before last, let me just yell and scream again in advance of anybody saying that the ACA ensures nobody will be left uninsured.   Arrrrrghhh!!   First of all: factually incorrect on many levels.  30 million people in the US will still be left uninsured.  And to add insult to injury, guess who subsidizes the cost of public health programs YET is not allowed to receive health care services through the very programs they pay for?   Yep, IMMIGRANTS.  For all ye liberals who like to drone on about how far we’ve come with the ACA, I ask one simple favor of you today: try not to get too excited yet.  Immigrants make it possible for Americans’ health care costs to be covered -- $10 billion (yes, that’s a “B”) was paid into the Medicare Hospital Insurance Trust Fund in 2009 by noncitizens.  Many of my friends who worked on the passage of the ACA work primarily with immigrant communities, and yet this point is not raised nearly as much as it needs to be, I feel.  Even though the famed “health care exchanges” are supposed to function as a marketplace where anybody can use their own hard-earned money to purchase a health insurance plan, the  marketplace will not accept the dollars of undocumented folks and folks who have papers but immigrated within the last 5 years.  Remember how I mentioned the high rates of cardiovascular disease and disturbingly low rates of screening for these and other conditions?  It’s not just South Asian immigrant communities that don’t screen for these.  Immigrant communities in general don’t get these tests done – and therefore end up having these chronic conditions get worse and worse, and therefore end up in the emergency room or at a point of no return which costs WAY TOO MUCH to care for – so much so that I know one too many immigrant families who have been bankrupted in the process of paying for cancer treatment, etc.  Well, yes, the fact that insurance companies charged for preventive services before was a factor contributing to this devastation, as was caps on services – both of which, thankfully, have been addressed by the ACA, sure.  But the other factor is immigration status itself.  This has NOT been addressed by the ACA.  Maybe insurance companies won’t charge co-pays and won’t have caps on services, but what if you’re not even allowed to purchase the bloody insurance plan?!  Yes, I know there is Emergency Medicaid.  But don’t even get me started about the hoops one has to go through to get this program to cover cost of care for needed services like chemotherapy and radiation.

There are a few things to feel proud of, yes.  The fact that Medicaid coverage has been expanded in most states, that you can receive tax subsidies to help with the cost of health care premiums under the exchanges, that small businesses and non-profits (with under 25 employees with average wages less than $50K) such as Many Languages One Voice, which offers full insurance coverage to its employees, can get a tax credit, that health insurance companies participating in the exchanges cannot discriminate based on sexual orientation or gender identity (holding my breath to see how this actually gets practiced by providers), and that dental services for kids will be offered through the exchange marketplace.   

However, I am saving my glitter and fanfare for the day we as a country can truly start to say we care about ALL our residents’ (yes, that includes IMMIGRANTS) health – the day we truly realize health care as a human right: the day when single-payer health care is a reality– which sadly, is not today, October 1^st, 2013.