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Editor’s
Note: An expanded version of this article will appear in the 100th issue of
our printed journal, HerbalGram, due out in November.
More than three years after the US Congress passed the Patient Protection and
Affordable Care Act (ACA), popularly known as “Obamacare,” the controversial
law maintains an undeniable presence in the lives of most Americans,
particularly considering the current political battle in Congress and federal
government shutdown.1
ACA-related debates abound, and discussions on its potential impact on natural and
integrative healthcare are no exception. Some in the complementary and
alternative medicine (CAM) community claim that the ACA removes freedom of
choice in healthcare. Other organizations celebrate the inclusion of CAM and
integrative health in various parts of the ACA and particularly embrace a provision
that calls for non-discrimination against licensed healthcare providers. Most
of this discussion centers on two aspects of the ACA: the individual mandate
and Section 2706, both of which are currently set to take effect in January
2014.
Individual Mandate
As of press time, all Americans must have health insurance at the start of 2014.2,3
Individuals without employer-based insurance who choose not to purchase a plan
on their own will be required to pay a penalty fee when filing their annual income
taxes. The individual penalty fee for 2014 is 1% of a person’s yearly income or
$95, whichever amount is higher.2 The fee increases each year; in
2016, for example, it will be the higher of 2.5% of a person’s yearly income or $695. Some
persons are exempted from this requirement, including very low-income
individuals and those whose religious beliefs are contradictory to purchasing
healthcare insurance plans (e.g., Christian Scientists, the Amish, etc.).
The ACA legislation explains that the requirement is expected to increase the
demand for healthcare services and thus increase supply and encourage competitive
prices; to reduce the $207 billion cost that the national economy sustains from
the “poorer health and shorter lifespan of the uninsured”; and to lower health
insurance premiums for all customers by reducing the “cost of providing
uncompensated care to the uninsured,” which was calculated at $43 billion in
2008.3
Various conservative and libertarian-leaning commentators and groups have
criticized the individual mandate for infringing on “basic” notions of
freedom and liberty. Some CAM customers and organizations, including
Citizens for Health (CFH) and the policy-focused nonprofit Alliance for Natural
Health-USA (ANH), also disagree with this tenet of the ACA.4,5
In 2010, CFH Chairman Jim Turner and Curt
Levey, the executive director of the nonprofit Committee for Justice,
published a joint editorial against the ACA before its passage. “Consumers of
alternative medicine are used to health insurance plans that offer little or no
coverage for holistic treatments and thus don’t meet their needs,” wrote Turner
and Levey. “That’s why many of them choose not to purchase health insurance.
What they’re not used to — but will have to get used to if the proposed
‘reforms’ become law — is being forced to purchase the very insurance plans
that fail to meet their needs. And therein lie the dire consequences of the
impending legislation.”5
Similar to CFH, ANH purports that many Americans’ lifestyles and values disagree
with typical insurance plans that generally cover only conventional healthcare
services and prescription drugs; the organization instead favors enabling
health consumers to spend their money on CAM products and services.4
According to Darrell Rogers, ANH’s campaigns and communications director, these
people often forgo the purchase of health insurance or choose a catastrophic
health plan, which has a lower premium (the amount of money one must pay each
month for the insurance) but a very high deductible (the amount of money a customer
must spend out of their own pocket before the health insurance begins its
coverage of services and medicines).6 The individual mandate,
however, will require both groups to purchase non-catastrophic, more standard
health insurance, theoretically leaving them with less money in their monthly
budget for their preferred CAM options. (Consumers
can retain existing “grandfathered”
health plans if they were enrolled in the plan before the date of ACA’s
enactment on March 23, 2010.)
“While catastrophic plans are permitted under ACA, they are restricted to
certain populations,” explained healthcare law attorneys Ryan Abbott, MD, a
professor at Southwestern Law School in Los Angeles, and Michael Cohen of the
Michael H. Cohen Law Group in Beverly Hills (email, December 3, 2012). “They
are available only to individuals who are under 30 years of age or who are
exempt from the individual responsibility requirement due to the affordability
exemption or the hardship exemption.”6
ANH noted that losing the catastrophic plan option will affect millions of
consumers. It bases this on the number of people who are enrolled in Health
Savings Accounts (HSAs), which are accounts for putting aside tax-free funds that
can be used on certain medical expenses. HSAs are available only to individuals
who have catastrophic or other high-deductible plans. As of January 2013, 15.5
million Americans were enrolled in HSA plans.7 This is up from 13.5
million in 2012 and 11.4 million in 2011. It is unclear, however, if these people
purchase high-deductible plans because it is their preferred option, because it
is the only option they can afford, or because it is the only plan offered by
their employer.
Although most Americans will not be able to purchase catastrophic insurance,
they still have the option to purchase a high-deductible health plan (HDHP)
that meets specific requirements.8 Unlike catastrophic coverage,
however, these plans typically have premiums similar to standard plans. Customers
who purchase HDHPs can take part in HSAs, which are attractive for CAM
consumers because certain CAM therapies are approved, such as acupuncture,
chiropractic care, and osteopathy. HSA funds also can be used to purchase herbal
dietary supplements and conventional nutritional dietary
supplements (vitamins, minerals, etc.), although these must “be recommended by
a medical practitioner as treatment for a specific medical condition diagnosed
by a physician.”9
“An HDHP with HSA is CAM consumers’ next
best option,” said attorney Dr. Abbott, “but they still have premiums which,
yes, should be higher than catastrophic plans. So, for someone really not wanting
conventional coverage, they’re stuck with a premium based on coverage they don’t
want.”
Those who wish to rely only on CAM are left with two additional, yet limited,
options: simply forgo insurance and pay the annual penalty fee or purchase an
unapproved plan (such as a catastrophic plan for non-exempt individuals) and
likewise pay the annual fee.
2706: A Provision for Non-Discrimination?
One of the facets of Obamacare most celebrated by natural medicine consumers is
Section 2706, known as the non-discrimination provision. This legislation
states that “a group health plan and a health insurance issuer offering group
or individual health insurance coverage shall not discriminate with respect to
participation under the plan or coverage against any health care provider who
is acting within the scope of that provider’s license or certification under
applicable State law.”3
Weeks of the Integrator Blog told
HerbalEGram that 2706 is the
“potentially most far-reaching” provision for the CAM community (email, November
19, 2012). As Weeks wrote in a recent Huffington Post column, this section was
authored by Senator Tom Harkin (D-Iowa), a long-time champion of natural health
causes in the US Congress, with input from various natural health organizations,
such as IHPC and the American Chiropractic Association.12
Weeks explained that the provision language seems to imply that if a certain
service is covered by an insurance plan, this plan cannot limit coverage to the
service performed by just MDs, and thus also must cover the service when
performed by other licensed practitioners. So if acupuncture is covered by a
person’s insurance plan, that person’s acupuncture treatment should be paid for
whether carried out by a physician or a licensed acupuncturist.10 Depending on how the provision is
interpreted, licensed CAM practitioners — such as naturopathic doctors in the 18
states that have provided a path to licensure — could possibly have their
services covered by insurance.11
“My position has always been that 2706 and the other points of inclusion in the
research, delivery, health promotion, and workforce provisions of the law are
historic in that they give integrative health and licensed so-called ‘CAM’
disciplines many points of legal standing inside the law,” said Weeks. “This is
historic. What is not historic is that with all legislation, this is just a
beginning.”
Weeks’s optimistic-yet-cautionary attitude is warranted. The remainder of 2706 includes
wording that makes the provision potentially less significant; it states, “This
section shall not require that a group health plan or health insurance issuer
contract with any health care provider willing to abide by the terms and
conditions for participation established by the plan or issuer.”3 This
is, however, typical insurance lingo and not just when there is a discussion
about CAM practitioners.
In April of 2013, the US Department of Health and Human Services (HHS) confirmed
that 2706
“does not require [insurance] plans or issuers to accept all types of providers
into a network,” and “does not govern provider reimbursement rates, which may
be subject to quality, performance, or market standards and considerations.”12
In response, Senator Harkin voiced concern in a report from the Senate
Health Education Labor and Pensions Committee and
directed “HHS to work with [the Department of Labor] and the Department of
Treasury to correct the FAQ to reflect the law and congressional intent within
30 days of enactment of this act.”13
Dr. Abbott and Weeks noted that 2706 likely would not see clarification unless it
is challenged in court. “Insurers are just supposed to make a good faith,
reasonable interpretation of the law,” said Dr. Abbott. “Litigation over this
provision is very likely.”
Until
then, the individual states hold the most power when it comes to deciding if
and which CAM services and/or
providers are covered. The ACA requires individual and small group market
health plans to offer essential health benefits (EHBs), which each state is in
charge of selecting.
“This will vary from state to state,” said Rogers of ANH, “and whether or not
CAM therapies will be covered depends entirely on the ‘typical plan’ selected
by the state. While some states like California and Washington have decided to
include acupuncture as one of services covered under the EHBs, most others have
not.”
Conclusion
Other
ACA provisions are expected to have small yet positive effects on natural
healthcare. The director of the
new Patient-Centered Outcomes Research Institute (PCORI) — the creation of which was called for in the ACA — has said that
CAM is a research area of interest.18 As of press time, PCORI had
funded two CAM-related studies and appointed several integrative medicine
practitioners to lead some of its workshops and panels.
ACA
additionally requires all plans in the Marketplace — the “exchange” gathering
all participating health insurance plans from which consumers can shop and
apply for coverage — to cover a number of preventive services at no cost to the
consumer, including blood pressure and cholesterol screening, diet counseling
for adults with a high risk of chronic disease, obesity screening and
counseling, folic acid supplements for women who may become pregnant, iron supplements for infants ages
6-to-12 months at risk for anemia, etc.15 It also encourages employer-based
wellness programs and mandates insurance coverage for certified midwives.
Unless Congress or the Obama Administration approve further delays or
clarifications in the remaining months of 2013, the ACA’s impact on natural
healthcare in the United States will begin to take shape after implementation
of the individual mandate and Section 2706 on January 1, 2014.
—Lindsay Stafford Mader
References 1. Weisman J, Calmes J. Obama summons
Congressional leaders to White House. New York Times. October 2, 2013.
Available here.
Accessed October 2, 2013. 2. What if someone doesn’t have health
coverage in 2014? HealthCare.gov website. Available here.
Accessed June 5, 2013. 3. Compilation of Patient Protection and
Affordable Care Act [as Amended through May 1, 2010]. Office of the Legislative
Counsel. May 2010. 4. Healthcare reform: overview. Alliance for
Natural Health – USA website. Available here. Accessed June 6, 2013. 5. Turner T, Levey
C. Reform
threatens alternative medicine. Citizens for Health website. March 18, 2010.
Available here. Accessed
September 5, 2013. 6. Can I buy a catastrophic plan?
Healthcare.gov. Available here. Accessed August 15,
2013. 7. Health savings account enrollment reaches
15.5 million [press release]. Washington, DC: America’s Health Insurance Plans.
June 26, 2013. Available here.
Accessed August 28, 2013. 8. What are the different types of health
insurance? Healthcare.gov. Available here. Accessed
August 15, 2013. 9. Department of the Treasury, Internal
Revenue Service. Publication 502. Medical and Dental Expenses (Including the
Health Coverage Tax Credit): For use in preparing 2012 Returns Cat. No. 15002Q.
Available here. Accessed August 29, 2013. 10. Weeks
J. Non-discrimination: a ‘big honking
lawsuit’ to advance integrative medicine and health? Huffington Post: Healthy
Living. June 3, 2013. Available here.
Accessed June 6, 2013. 11. Health care reform extends reach of naturopathic medicine. Bastyr
University website. January 24, 2013. Available here. Accessed September 5, 2013. 12. FAQs about the Affordable Care Act Implementation
Part XV. United States Department of Labor, Employee Benefits Security
Administration. April 29, 2013. Available here.
Accessed August 29, 2013. 13. Weeks
J. Harkin pushes back on HHS for broader interpretation
of “non-discrimination in healthcare” - Section 2706. Integrative Practitioner
website. August 2013. Available here.
Accessed August 30, 2013. 14. Weeks J. Integrative medicine, complementary
and alternative medicine and health round-up #66: April 2013. Available here.
Accessed August 30, 2013. 15. What are my preventive care
benefits? Healthcare.gov. Available here. Accessed August 30,
2013. |
