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The Controversy Continues

The Affordable Care Act (ACA) continues to be extremely controversial. The legislation has split the medical community, with passionate views on both sides. The challenge for Chicago Medicine is to report fairly on the Act, present both sides, and provide timely information. The last goal is particularly difficult to achieve because of the ever-changing ACA landscape. Despite the inherent risks of controversy, the editors believe the Chicago Medical Society (CMS) is obligated to deal with the Act in a balanced and responsible manner.

The Goals
Most physicians would likely support the goals of the Act: to provide insurance to more individuals at a reasonable price. Certainly, the present system has major coverage gaps.  In Illinois, about 1.7 million, or 13% of the population, is uninsured. Cook County alone has an estimated 855,000 uninsured.

All plans offered through the new Health Insurance Exchanges must cover ten different areas: hospitalization, emergency room, laboratory services, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitative services, preventative medicine, ambulatory care, pediatric vision and dental services. In addition, the ACA provides guaranteed coverage and coverage for dependent children up to age 26; it eliminates pre-existing diagnoses, and lifetime and annual limits.

The levels of coverage are based on the actuarial levels of coverage: 90%, 80%, 70% or 60%. When individuals are enrolled onto the exchange, they may become eligible for government assistance. Cost-sharing subsidies are available for individuals with household incomes below 250% of the Federal Poverty Level (FPL). Premium tax credits and out-of-pocket maximum subsidies are available for those with incomes below 400% of the FPL. It has been predicted that the majority of individuals buying insurance through the Exchange would be eligible for some government support.

The ACA also has a significantly expanded Public Aid component. The Congressional Budget Office predicted that nine million more Americans would be enrolled in Public Aid, with seven million more being privately insured through the exchanges in 2014.

The Challenges
By late October, there were significant challenges to the entire system. The most obvious has been the poorly functioning federal website where individuals from 36 states can apply for coverage. HHS Secretary Kathleen Sebelius has promised an efficient website by the end of November. Some of the 14 state-run exchanges have been operating much more efficiently.

An Oct. 13, 2013, Chicago Tribune analysis of the exchange offerings indicated that coverage may be less affordable than desired. The lowest-priced Cook County plans were reviewed, and 21 out of 22 plans had annual deductibles of at least $4,000 for individuals and $8,000 for families. Certainly, those numbers are not in the reach of most families. However, government assistance may help defray some of the costs.

In addition, the individual insurance policies many Americans currently have are not likely to be available in the future due to the Act's requirements, including mandatory coverage in the ten areas. In fact, the HHS “regulatory impact analysis” indicated that 40-67% of current individual plans would not qualify as permitted plans. As such, literally millions of Americans with individual policies have been getting termination notices, and will likely have to purchase new plans through the exchanges.

Even in states with functioning exchanges, the enrollment into Public Aid has been strong, but far less so in the private insurance market. In the first three weeks of October, enrollment through the state exchanges included high Public Aid rates: Washington 87%, Kentucky 82%, and New York 64%.

Obviously, the Affordable Care Act's roll-out has not dampened the controversy. As Chicago Medicine brings objective and balanced reporting to this divisive subject, the editors encourage CMS members to participate in our own debates on controversial issues, including the ACA, on our website,

Robert W. Panton, MD
President, Chicago Medical Society

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