State-based health exchanges, a key component of the Affordable Care Act, are being challenged and essentially stopped dead in their tracks in many states due to opposition to the controversial health care law passed in March 2010. State health exchanges, online portals similar to priceline.com where uninsured Americans will login to view their health insurance options and subside levels up to 400% of the Federal Poverty Level, will not be activated until January 1, 2014 unless the Supreme Court strikes the entire bill as unconstitutional next month. Make no mistake, come 2014 these exchanges will play a large roll in changing how uninsured Americans gain access to health insurance. An estimated 33 million uninsured Americans will gain access to health insurance over the next ten years, with nearly 17 million likely use the state-based health exchanges to shop for their preferred health plan. (the remaining 16 million will be added to existing Medicaid rolls)
Many of the 26 states who are fighting to have the health care law thrown out completely, are choosing to wait until after the Supreme Court ruling on the constitutionality of the controversial legislation, which makes sense. However, individual states are required to set up their own health exchanges, or they will be forced to participate in a Federal exchange. So, while we can continue to fight the laws’ implementation, if the Supreme Court upholds the individual mandate included in the bill, it will be the law of the land, and we need to act proactively to ensure orthotics and prosthetics continue to be covered and offered on the yet to be setup health exchanges. More than $850 million has been appropriated to individual states to aid in developing their own exchanges, but few states have actually setup an exchange as of June 2012. Expect a flurry of activity on exchanges if the Supreme Court rules the bill constitutional.
How does O&P fit into these state-based health exchanges and what can our profession do to be in a position to take advantage of the 33 million newly insured patients? In order for a private insurance company to offer their plans on the health exchanges, they must offer what is called the “essential health benefits package”, the absolute minimum insurance plan coverage that can be offered on the exchanges. Each individual state must determine their own essential health benefits package from ten sample plans currently being offered in their state:
A study commissioned last year found O&P were included in nearly 75% of small group insurance plans and most state/federal employee plans offer O&P coverage, so O&P logically should be present in most essential benefits packages. However, “should be” is never good enough. O&P practitioners must focus our efforts on contacting state legislators and insurance commissioners to lobby for the inclusion of orthotics and prosthetics in the essential benefits package in all 50 states, or risk having limited access to the nearly 17 million patients that are likely to use the exchanges to gain insurance coverage in the years to come.
State governments — legislators, insurance commissioners and even governors in many cases — are much easier to meet and discuss our issues with than members of congress. We need to develop relationships with our local representatives, Republican or Democrat, and get them to understand what we do for our patients and the type of technology used to give people their life back. Attend a town hall, schedule a meeting at the state capitol, write an email or make a phone call — just make a connection!
OPGA wants to help independent O&P practitioners survive the regulatory challenges and initiatives of health care reform that threaten the O&P profession. Contact OPGA for help contacting your state legislators or insurance commissioners. firstname.lastname@example.org
A map detailing the status of state based health exchange in all 50 states can be found here.