Editor’s Opinion: Ready or Not. The New Year is Here!

  A new 12 months seems like a lot of time, at least for a few days in January. Will the new year have even more surprises in store than the year before? What is around the corner?   One thing definitely around our corner is full implementation of the 2010 Affordable Care Act. When it was signed into law, the year 2014 seemed far away. From day one, a number of states vowed to not participate in the expansion of Medicaid as one of two main ways to expand healthcare coverage to the uninsured. The ink on the new law was barely dry before the first legal challenge was filed. Uncertainty about the outcome of these legal actions, fundamental resistance of some governors to expand Medicaid, combined with hopes that perhaps a different administration would take over in Washington this year have caused major implementation delays. As of this writing, 15 states had committed to participate some time ago, most remain undecided, and approximately nine states are likely to remain in the “definitely not” column.   Many aspects of the new law already have gone into effect. Payments for healthcare providers in medically underserved, mostly rural, communities have increased, while copayments for annual wellness visits, flu shots, and recommended screenings (eg, colorectal cancer screening, mammograms, cholesterol screening) have disappeared from many health insurance plans. At the end of last year, value-based purchasing programs for Medicare patients admitted to acute care facilities were implemented, and patient satisfaction has become an important outcome measure.

  So what is going to happen this year? For starters, this month states are supposed to expand coverage for persons insured through Medicaid by providing preventive services such as immunizations without a copayment. Also this month, the Act requires states to pay primary care physicians who take care of Medicaid patients no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services. This increase is fully funded by the federal government and should not affect state budgets. Finally, this month marks the start of a 2.3% excise tax on medical devices and a national pilot program for hospitals to “bundle” payments for Medicare patients.

  Other changes to come depend, to some extent, on the actions of your state legislators. For example, the majority (about 60%) of individual and small market health insurance plans available today do not cover a variety of important services such as maternity or mental health services. Starting in January 2014, all new plans must include a set of so-called essential health services, including maternity and newborn care.

  In 2011, individual states were asked to choose from a range of existing and popular health insurance plans to serve as benchmarks¹; as of the end of last year, only 26 states and the District of Columbia complied. If the plans available in the Health Insurance Exchange program do not cover essential benefits, other programs such as the State’s Children’s Health Insurance Program (CHIP) may have to expand to comply with the new law.

  According to a study conducted at the Urban Institute for the Kaiser Family Foundation’s Commission on Medicaid (available at: www.kff.org/medicaid/kcmu112612nr.cfm), this is one example of why states that will not expand their Medicaid program may end up spending more money than those that opt in. Some provisions of the Act will go into effect regardless of what the state decided, but states that opted out will not receive federal assistance to help pay for it. Ironically, many of the states that opted out completely have the highest rates of uninsured persons in the country and they somehow will have to pay for the federally mandated expanded coverage without receiving money from Washington.

  Regardless of where you practice, because of all the legal challenges and uncertainties, most states will spend the rest of this year scrambling to prepare for open enrollment in October 2013. Will persons who previously overwhelmed emergency departments because hospitals were their provider of last-resort start flooding your office as soon as they are able to purchase insurance through the exchange or have become eligible for Medicaid? Will the influx of new patients be our January 2014 “ready or not” story? Have you prepared yourself, physically (by resolving to practice your own good health habits) and emotionally (by finding dependable ways to de-stress)? Time will tell. Have those sturdy work shoes and comfy running shoes at the ready. You will need them! Meantime, we wish our readers a happy and healthy 2013.

 This article was not subject to the Ostomy Wound Management peer-review process.

1. Henry J. Kaiser Family Foundation. Essential Health Benefits: What Have States Decided for Their Benchmarks? December 7, 2012. Available at: www.kff.org/healthreform/quicktake_essential_health_benefits.cfm. Accessed December 30, 2012.