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ACA: Basics

Moving Forward… Protecting Our Care

Today we celebrate – one year ago today, President Obama signed landmark health care legislation, the Affordable Care Act (ACA). This legislation provides unprecedented levels of security and choice around health care. Wisconsinites are already feeling the benefits, and our state has received millions in federal funds to support implementation of the law.

A Kaiser Family Foundation survey reported last week that most Americans are confused about the health care law. In fact, according to the poll, “confused” outranks “angry,” “anxious” and “enthusiastic” as a descriptor. This is why advocates and health care supporters from across the country are coming together to mark this one year anniversary, to clear up some of the confusion around the law, and show all the ways in which it is benefiting our lives.

Throughout the week, we have noted the impact on small businesses and seniors, and will be discussing women and young people. Today, we will be looking at the patient protections incorporated in the Affordable Care Act.

  • The Affordable Care Act Ends The Worst Insurance Company Abuses Such As Denying Coverage Because Of A Pre-Existing Condition. Already, the law bans insurance companies from dropping coverage when you get sick and excluding children with pre-ex conditions from coverage. Those protections will be extended to everyone in 2014. [, Fact Sheet: The Six Month Anniversary of the Affordable Care Act, 9/22/10]
  • The Affordable Care Act Lowers Premiums For You And Your Family. The nonpartisan Congressional Budget Office examined provisions in the Affordable Care Act and found that it would cut premiums for millions of Americans, particularly those in the individual market. Those in the individual market who get help to pay for their premiums are expected to see their premiums drop an average of 59 percent compared to what they would pay had we not passed the law. Another report showed families will save $2,500 by 2019 compared to what they would pay had the law not been passed. [CBO, 11/30/09; Commonwealth Fund/Center for American Progress, May 2010]
  • The Affordable Care Act Ends Lifetime Limits On Your Coverage. Because of the Affordable Care Act, insurance companies can no longer put lifetime limits on the amount of health coverage you can receive. It also restricts annual limits and eliminates any cap by 2014. [, Fact Sheet: The Six Month Anniversary of the Affordable Care Act, 9/22/10]
  • The Affordable Care Act Cracks Down On Excessive Premium Rate Increases. Because of the law, the federal government has made $250 million available to states to help them develop and implement the tools necessary to crack down on excessive rate hikes. In addition, insurers that are found to raise rates too much can be banned from participating in the new health exchanges that will be available in 2014. [, Rate Review Fact Sheet, 2/24/11]
  • The Affordable Care Act Gives You The Freedom To Choose Your Doctor. The Affordable Care Act takes away the power to choose your doctor from insurance companies and gives it to you. Now, if you purchase a new plan, you have the freedom to choose your own doctor in your insurer network. The benefit of protecting primary care provider choice is expected to help up to 88 million people by 2013. [, Fact Sheet: The Six Month Anniversary of the Affordable Care Act, 9/22/10]
  • The Affordable Care Act Ensures Your Premium Dollars Are Spent On Your Care, Not Insurance Company Profits. Because of the law, insurers in the large group market must spend at least 85 percent of your premium dollars on care, not administrative costs like their profits. For the individual and small group markets, insurers must spend 80 percent of your premium dollars on care. In addition, insurers will be required to publicly disclose their rates on a new national consumer website – [, Patient’s Bill of Rights]


One of the most critical pieces of the Affordable Care Act is to be implemented by the states, a health insurance marketplace, or exchange, to be up and running by January 2014. These exchanges are envisioned to bring high-quality, easy-to-understand health coverage options to consumers. States are left with a great deal of flexibility to create exchanges, to meet the federal standards. Therefore, it is extremely important that advocates for health reform continue to stay active in their state implementation process. [The Commonwealth Fund, States in Action – Health Insurance Exchanges]

Because of early work by the Doyle Administration, Wisconsin was one of only seven states to receive an early innovator grant, to work on a model IT exchange. On top of this, we were granted nearly $1 million more for exchange planning alone. Despite overwhelming benefits to the citizens of Wisconsin, the Walker Administration has made clear that they do not support the Affordable Care Act. When asked at the HealthWatch Wisconsin conference why Wisconsin accepted the early innovator grant, Department of Health Services Secretary Dennis Smith replied that they see benefits for the insurance industry by implementing an exchange. This is not the goal of health insurance exchanges. We must work to ensure that our exchange is consumer focused and an active purchaser model, where the state regulates plans in the exchange for quality. Below are some benchmarks for an effective Wisconsin exchange:

  • Exchange planning, implementation, and governance should all function transparently and should be receptive to public input.
  • The governing body of the exchange should have strong conflict of interest requirements.
  • The exchange operating entity should abide by open meeting laws and strong transparency and accountability provisions.
  • The exchange should pay particular care to individuals who, due to fluctuations in income, transition between public coverage like Medicaid and private coverage through the exchange.
  • Wisconsin should take an active role in making sure that only health plans that provide good value to consumers are permitted to sell coverage through the exchange, act as an active purchaser. Factors that indicate “good value” could include scoring well on quality indicators and having provider networks that meet enrollees’ needs, while charging reasonable premiums and demonstrating a history of seeking only reasonable rate increases.
  • Wisconsin should ensure that plans are easily understandable, of comparable and standardized options. We may also want to consider ensuring that plans outside the exchange adhere to these standards, to more easily compare exchange to non-exchange plans.
  • Similarly, Wisconsin should enact policies to prevent adverse selection and to ensure the stability of the exchange. The state should require insurance plans sold outside the exchange to comply with all of the same consumer protection requirements that health plans inside the exchange must meet. We should also take measures to ensure that plans outside the exchange aren’t operating just to attract the lowest cost, healthiest enrollees. For example, like insurers inside the exchange, insurers operating outside should be required to sell at least one silver level plan and one gold level plan. The state should also make sure that brokers do not have incentives, such as higher commissions, to steer residents into coverage outside the exchange.
  • Exchange features should be tested with diverse consumers before their implementation. After exchange implementation, a formal feedback loop should be available to consumers and their representatives so that any problems with exchange functioning can be reported and addressed.
  • The exchange should provide appropriate language services to meet the needs of individuals who do not speak English or who have limited-English proficiency.

There is much work to be done – stay actively involved to ensure that we move forward to protect and enhance our care.



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