Nearly a decade after it was passed, the Patient Protection and Affordable Care Act (ACA) — also glowingly or disparagingly referred to as “Obamacare,” depending on a person’s politics — has become a pawn, another arrow in the arsenal of weapons brandished between liberals and conservatives, legislators of all stripes, consumers and insurers. And as the political climate continues to ratchet up, jousting over the ACA is intensifying — from neighbors’ disagreements over fences to arguments in the U.S. Supreme Court.
Often lost in the noise is the effects it has had for those who have the greatest stake: seniors — particularly those who have low incomes.
In fact, some of the law’s most sweeping changes were of the most benefit to seniors — including improvements to Medicare, streamlined and cleaned up procedures for those qualified for both Medicare and Medicaid, also called “dual eligibles,” and other consumer protections to healthcare rights. Without those changes, an estimated 4.5 million older adults were targeted to lose their health insurance completely .
Changes to Medicaid and Medi-Cal
The ACA broadly expanded Medicaid and Medi-Cal coverage to adults under age 65 who have low incomes — a change that on its own cut the uninsured rate for those between the ages of 50 and 64 in half. Because of that expanded coverage, overall health care costs for people who begin Medicare coverage at age 65 are also projected to decrease over the years as long as the ACA remains in effect.
Help for aging in place. As is often researched and reported, most older people insist they would prefer to remain in their homes as they age rather than move into facilities. The ACA helped make that more possible by shifting the focus of dollars spent from institutional care to home-based and community-based services.
For example, the Community First Choice Option provides participating states with matching federal funds to pay for personal care services for those living in their homes and communities who require an institutional level of care. For those who do not need such intensive care, another program, Section 1915(i), can provide services tailored to specific populations, such as older adults.
The ACA also established the Money Follows the Person program, with funds earmarked to help people move from nursing facilities back into their communities. And finally, it extended the “spousal impoverishment protection” under Medicaid and Medi-Cal so that one spouse can keep more assets and income if the other requires nursing home, in-home, or community type care services.
Simplified eligibility and enrollment. The ACA simplified eligibility and enrollment procedures for Medicaid and Medi-Cal by introducing online and telephone applications and eliminating face-to-face interviews, which were an insurmountable barrier for many older people. It also greatly simplified eligibility standards, eliminating the worky steps of counting assets and calculating deductions.
Increased coverage options. The ACA offers premium tax credits to people with incomes between 100% and 400% of the federal poverty level and established plans with reduced deductibles and cost-sharing — enabling more than 3 million low and moderate-income adults to purchase health insurance coverage.
Age and pre-existing condition protections. Before the ACA took effect, more than one in five older adults who were not yet qualified for Medicare were completely denied coverage. There were no limits on how much an insurer could charge based on age, and women had to pay higher premiums — from 50% to 80% more — than men, based on the debatable claim that they consume more medical care. Also, while nearly 85% of adults ages 55 to 64 have at least one preexisting condition, many people were denied coverage or charged exorbitant premiums because of them in the past. The ACA eliminated these discriminatory practices.
Essential coverage standards. Ferreting out much substandard and deceptive coverage, the ACA mandated that most plans must provide coverage for 10 essential health benefits: hospitalization, emergency services, outpatient care, maternity care, mental health and substance abuse treatment, laboratory services, prescription drugs, rehab services, preventive services without cost-sharing, and pediatric oral and vision care.
Changes to Medicare
Most seniors aged 65 and older are covered by Medicare — though there had long been criticism of the gaps in the program and the high share of costs many had to pay. In addition to earmarking more than $350 million and putting teeth into provisions to fight Medicare fraud, the health care law made a number of other changes to the program.
Cost-sharing eliminated. The ACA did away with the need for beneficiaries to share the costs of many preventive services — including annual wellness visits, mammograms, pap smears, bone mass measurements for those with osteoporosis, as well as screenings for depression, diabetes, HIV, and obesity.
Prescription D coverage. After Medicare Part D paid a certain amount of costs, some enrolled lost coverage until their out-of-pocket spending hit a certain amount, though there were required to keep paying premiums — a gap in coverage known as the “donut hole.” The ACA instituted a plan to gradually phase out the donut hole by the year 2020, initially through rebate checks and prescription discounts — saving an estimated 12 million Medicare beneficiaries nearly $27 billion in out-of-pocket payments for prescriptions.
Required drug coverage. The ACA protects coverage for a number of drugs — among them: antidepressants, antipsychotics, and immunosuppressants, which are used most often by older patients .
Low-income subsidies expanded. The Low-Income Subsidy (LIS) was created when Part D was added to Medicare to help cover premiums and cost-sharing for low-income beneficiaries. The ACA eliminated cost-sharing for Part D drugs for those who require institutional care, extended LIS eligibility for those whose spouses die, and permitting plans to waive premiums for LIS recipients.