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Thursday, December 16, 2010

When do we get our free preventive health care?

One of the most exasperating things about the Affordable Care Act (otherwise known as health care reform) is the fact that its many provisions don’t just start immediately, but rather are phased in over a really long period and at seemingly random intervals.

As a physician, I often hear my insured patients say things like “I can’t afford a colonoscopy right now” or “how much will a mammogram cost me?” I tell them that with the health care reform legislation they won’t have to pay for either one of these things. Unfortunately, my response has been a misleading oversimplification.

It is true that one of the most welcome parts of the Affordable Care Act is that recommended preventive care services will be paid for in full, without co-pays or cost sharing. But when?

Medicare and Medicaid programs will begin covering preventive care services at 100% on January 1, 2011. The services included are at this link: http://www.healthcare.gov/law/about/provisions/services/lists.html

Private insurance companies have a year from the passage of the law to comply with this provision. So if you are privately insured, you may need to wait for several more months.

But what about the people who are told by their insurance companies, that, no, they don’t have coverage for colonoscopies or pap smears or flu shots or smoking cessation counseling or any of that stuff? Doesn’t the law apply to everybody?

Because the health care reform law had to allow people to keep the insurance coverage they had if they wanted to keep it, certain policies are “grandfathered” so that they remain the same as they were at or prior to March 14, 2010. Any insurance policy that a person maintains continuously, that doesn’t change its provisions in any significant way, can continue to not provide fully covered preventive care services. If the policy changes its coverage limits or the services it covers, that policy is no longer grandfathered and must fully comply with the law.

Most of the other provisions of the health care reform package do apply to these grandfathered policies, except for the fact that an individually insured person who was not covered for a pre-existing condition that was excluded will remain that way, and that there may not be full coverage for visits to pediatricians or gynecologists.


Why would a person want to stay insured under one of these grandfathered policies? Probably because the private health insurance companies are at this point doing their very best to increase the prices on new policies before many of the other provisions of the act go into effect in 2014 and thus the cost of the newly created policies that conform to the new law is pretty steep, in many instances. Private health insurance is presently going from wickedly expensive to unaffordable for many Americans. Keeping one’s old policy, even with nasty rate hikes may be the only option many people see open to them.

Why do health insurance companies not voluntarily cover preventive services? Surely it saves them money to prevent rather than treat disease. Unfortunately that is not always true. If all women received mammogram screening at recommended intervals, the cost per year of life saved would be 40-50,000 dollars. If a person doesn’t receive timely screening, the breast cancer that results might be expensive to treat, but that will be offset by the many women who never had mammograms. In addition, some people who are not screened for disease die quickly and relatively inexpensively. Those who survive will likely be costlier to treat in the future. It is not in the best interest of an insurance company whose motive is profit to aggressively screen for most diseases.