Cruelty or Care? The Choice is Yours

By Pippa Abston, M.D.
Pippa Abston’s blog, May 22, 2013

Well. From the beginning, I have been telling you all that the so called “Patient Protection and Affordable Care Act” is neither protective nor affordable to patients. We can keep the same PPACA abbreviation and call it what it is: The Profiteering Protection and Affordable Cruelty Act. Although I read the whole darn thing, I lack a background in law or politics. As the specific corporate protections emerge from this convoluted mess, I have to say I didn’t foresee some of them. I knew it would be bad, just not all the details of said badness.

The latest in our story of woe? Insurers and some employers have discovered an irresistible loophole that allows skimpy policies covering only a few outpatient services. The key phrase is “minimal essential coverage,” previously defined in federal law under the IRS Act of 1986. I noticed some folks had conflated that term with “essential health benefits,” but EHB are mandated items on state Exchange policies starting in 2014. No plan will be allowed to put lifetime or annual dollar limits on coverage, but outside of the Exchanges, other details of minimal essential coverage are minimally described.

I think I was fooled by the ACA’s opening paragraphs allowing insurers to temporarily restrict annual limits on essential health benefits until 2014. I missed the absence of any requirement to offer those benefits at all, at any date, except on the Exchanges. Insurer can’t restrict annual dollar amounts of those benefits if they are offered. In a stunning twist on catastrophic coverage, it is possible for insurers to cover only the required preventive services and omit the catastrophes. You can get your colonoscopy “free” if you have a non-grandfathered plan, but any follow-up surgery is entirely on you.

The most minor effect is that employers who offer bare-bones policies and employees who get them are exempt from the ACA penalties. I see some reference to this loophole only applying to large employers, but I don’t know how that was determined. I don’t see it in the IRS code that I found, which includes as minimal essential coverage “B) any other plan or coverage offered in the small or large group market within a State” —it may be elsewhere. It seems to me it would apply to any size group policy offered outside of the Exchanges. If one of you can find me the relevant law making this only applicable to large employers, I’d be grateful.

The worst effect is that employees who have minimal essential coverage are not eligible for premium subsidies on the Exchanges, as far as I can tell. This also seems to be the IRS’s interpretation: “A month is not a coverage month for an individual, and thus no premium tax credit is allowable for the individual’s coverage, if the individual is eligible for minimum essential coverage other than coverage offered in the individual market for that month.” If you can show me in the law itself or in administrative policy how it can be read otherwise, please post a link. Maybe the IRS can do some creative adjusting. Generally their creativity seems to apply only to corporations.

How many employers will use these plans to avoid penalties and thus apply this affordable cruelty to their employees in the process? You know it will start with those who already pay poor wages. As health care costs rise, don’t be surprised if you get this offer you can’t refuse in your own benefits package.

Do I have grounds to put the word “cruelty” in place of “care” in the ACA? The law is no longer new. It is now part of our health care system. I don’t know what else to call a system that not only allows but entrenches the abuses I see in my office. Children who desperately need skilled child psychiatrists but whose insurance does not have a single child psychiatrist, skilled or unskilled, on the panel. Children who don’t get the care they need because their parents delay over co-pays and deductibles. Parents who work long, hard hours at low pay, producing goods and services we use without gratitude or notice, whose “non-emergency” pain goes untreated because of money. Who try to smile at me in front of their kids, as if it doesn’t hurt, but cry when I take them in another room. I refuse to make excuses for this awfulness or play around with euphemisms. Cruelty, brutality, callousness — many words apply, and none of them is “care.”

I can hear the defensive talk already, from people who won’t be able to believe their beloved party would intentionally expose us to this treatment. It was an oversight, right? The law is complicated. We missed this problem, and they did too. We have a bumbling, well-meaning but hapless government, like a dog that’s so ugly it’s almost cute. Don’t buy it. Somebody had better ask what the President and insurers knew and when they knew it. Remember the industry was mighty cozy with our Executive Branch during construction of the law. Is it just now that this minimalist option has been discovered? Or is this a convenient time for discovery, well into the second term? Will we allow the President to wash his hands of the disaster and pretend he never imagined anyone would behave so?

What will it be, folks? Do you want to keep trying to pass legislation to close loopholes, even though the insurers are always one step ahead? How long will you continue to support and vote for people who cater to them? When will you finally say “don’t let the door hit your butt on the way out” — and insist on real insurance and real representation?

Improved, expanded Medicare for All is a simple, achievable, affordable, practical next step. It doesn’t require revolution, utopia or socialism. Even conservatives can embrace it. We have the structure in place. We are only waiting for you. Will you speak up?

Pippa Abston, M.D., Ph.D., F.A.A.P., is a pediatrician. She resides in Huntsville, Ala.

http://pippaabston.wordpress.com/2013/05/22/cruelty-or-care-the-choice-is-yours/