prosthetics and health care reform


Some of you may have heard that there was a national election recently. With Nate Silver now the political equivalent of Billy Beane circa 2004, I thought it appropriate to dive below the headlines of the left and right, which, depending on which side you favor, auger either (a) the final step in America’s rush towards disintegration, or (b) our continued ascendance towards never-ending bliss (aided, in a few states, by a long drag on a now-legal spiff). More specifically, there was this little thing called health care reform that occupied a lot of people’s attention the last four years.

Now that Americans have clearly spoken, voicing their displeasure with the vitriolic, he-said/she-said politics of the past, and signaling their desire for profound change by bringing back basically the same cast of characters we all spent much of the election cycle bemoaning, it makes sense to try to get our heads around one of the most divisive issues of President Obama’s first term: health care reform. More specifically, what, if anything, does health care reform mean for those of us who use  (or would like to use) a prosthesis? With the caveat that forecasting how health care reform will actually work is about as scientific as Dick Morris’s pre-election predictions, here’s a snapshot of the next 24 months.

2013

The two biggest changes coming in 2013 don’t directly relate to how we receive health care. First, a 2.3% tax on medical devices is scheduled to take effect for products sold after January 1, 2013. The scope of that tax – i.e., does it apply to prosthetic components? – remains unclear at this point, though regulatory guidance from the IRS earlier this year suggested that prosthetics would not be subject to it. Second, required reporting of payments to physicians by manufacturers of medical devices and pharmaceutical companies will begin. The purpose of this measure is to expose the financial relationships between the people treating us and the companies vying for their loyalty. Would you like to know if Dr. Jones is getting paid by Company X to prescribe you Drug Y? If you have the patience to wade through a yet-to-be-created government database to find out, soon that information will be yours to consume. (If the government makes it as user-friendly and attractive as other government websites, I feel confident in saying that it may get as many as 30 or 40 hits a year before users give up in disgust.)

2014

Beginning in 2014, people will need to comply with the health care reform law’s so-called “individual mandate”, which requires them to obtain insurance. People will do this in one of 3 ways: (1) through their employer (just as they do today); (2) through a health insurance exchange administered by their state (a new mechanism); or (3) through Medicaid (which the Federal government is expanding to cover more people). Of these 3, health insurance exchanges are the new kid on the block.

Modeled on exchanges created as part of Massachusetts’ health care reform law when Mitt Romney (remember him?) was governor, the state-run exchanges will provide a “one-stop shop” model for consumers where they can purchase health insurance. In order to protect consumers from hidden differences between policies, the government is requiring all plans offered through the exchanges to have the same set of basic benefits: “essential health benefits.”

A key question facing people with limb loss as health insurance exchanges ramp up is whether prosthetics constitute an essential health benefit. If yes, then policies excluding prosthetics become a thing of the past; if no, then insurers could choose not to offer them as a standard benefit.

To date, the government has declined to take a hard position on what constitute essential health benefits. In fact, after passage of the health care reform law, the government played “kick the can” with the issue, telling states that they should look to “standard” plans offered within their borders to determine what constituted essential health benefits. While this insulated the government (and White House) from yet more contentious health care debates as an election loomed, proponents of the reform law noted that the decision created the possibility of 50 different decisions regarding essential health benefits.

Most experts believe that the government will issue guidance on essential health benefits in the coming weeks now that the election is over. While the prosthetics industry argues – correctly, in my view – that prosthetics are essential health benefits within the meaning of the health care reform law’s language referencing “rehabilitative and habilitative” equipment, the fact remains that the law does not specifically mention prosthetics, so this remains an important issue to watch in the coming months.

Also coming in 2014 – the elimination of pre-existing risk exclusions. For amputees, this should be a welcome change. If on January 1, 2014 you have no insurance  and need a new prosthesis, you will be eligible to get one immediately after purchasing your new insurance policy without any kind of exclusionary period. (Assuming, of course, that prosthetics are an essential health benefit or are otherwise covered by the policy).

Finally, 2014 will also mark the end of insurance policies with lifetime or annual limits. Again, this should help people with limb loss/difference. Where policies today might contain a “$5,000/year” or “one prosthesis per lifetime” limit, tomorrow’s health insurance policies will eliminate these restrictions (again, assuming that prosthetics are an essential health benefit).

conclusion

As you can see, the “essential health benefits” issue permeates virtually every key potential benefit offered by health care reform in 2014 and beyond. For an incredibly detailed analysis of that issue, you can click here.

One final thought: whether you like “Obamacare” or not, the economic and clinical data show that maintaining the health care status quo is not sustainable. The United States spends more on health care and gets worse results per dollar than most countries when looking at key indicators. The battle for health care reform was never about should we do it, but rather, how to get there. President Obama’s legacy will be inextricably tied to health care reform. With reform surviving both constitutional review and the 2012 elections, the law’s implementation will begin to shape that legacy, starting now.

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