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What’s changed, what’s coming and how Obamacare affects you

Rosemary Jaffe who 60 years old is looking forward Affordable Care Act's 2014 provisions kicking so she can hopefully get

Rosemary Jaffe, who at 60 years old, is looking forward to the Affordable Care Act's 2014 provisions kicking in so she can hopefully get insurance. She lost insurance when her husband died and she can't get Medicare for a few years. She attended the American Heart Association's "Go Red for women" conference at Macy's State St. store Friday, March 1, 2013. | Rich Hein~Sun-Times

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Updated: April 4, 2013 6:19AM

What has changed:

* Illinois set up temporary high-risk insurance pool for people who couldn’t get affordable coverage because of a pre-existing condition. This pool started accepting people in 2011. The idea was to provide a bridge until 2014, when the pool will be replaced with state-based insurance exchanges that are supposed to let people shop for low-cost health insurance. More than 3,300 Illinois residents are currently enrolled under the Preexisting Condition Insurance Plan, which stopped accepting new members last week.

* Beginning in 2010, insurance companies were no longer allowed to deny health insurance to children because they have a pre-existing medical condition. That provision was expected to help an estimated 226,900 children in Illinois, according to an analysis by the consumer group Families USA. Young adults who do not have employer-sponsored health coverage are also stay on their parents’ insurance plan until they’re 26, a change that has helped 125,000 uninsured young adults in the state, the federal government estimated. In Indiana, 121,400 children had pre-existing conditions that would have resulted in denial of coverage, according to data from 2010.

* Hospitals are paying closer attention to readmission rates, which theoretically should lead to better care for patients. The Washington Post reported that, according to statistics compiled by the Obama administration, the nationwide rate of hospital readmissions of Medicare patients within 30 days of discharge declined to about 17.8 percent by last November after remaining stuck near 19 percent over the five years that the data has been collected, and likely for decades prior to that. The Centers for Medicare and Medicaid Services began keeping track of that rate for hospitals, and the federal government began imposing penalties for excessive numbers of repeat patient visits. Many hospitals have since noted ways they are trying to reduce readmissions.

* Illinois Medicare beneficiaries saved an average of $657 per person and a total of $56 million last year, upon receiving a 50 percent discount on prescription drugs after they hit the so-called donut hole, according to the government. In Indiana, the “donut hole” discount averaged $646 per person, and a total savings of nearly $36 million in 2012.

What is changing now:

* Nationwide, hospital systems are merging and snapping up doctor practices, in part to get more capital for necessary changes like switching to electronic health records. Recent mergers in the Chicago area include Edward Hospital and Elmhurst Memorial Healthcare, Central DuPage Health and Delnor Community Health System and the Provena Health system and Resurrection Health Care. In explaining her merger with Elmhurst Memorial, Edward’s President and CEO Pam Davis said, “The delivery of healthcare is changing rapidly. Hospitals are under tremendous cost pressure while being asked to take a much more active role in managing the overall health of patients. Together, Edward and Elmhurst can enhance the quality and cost effectiveness of healthcare while still maintaining our strong local community focus.”

* A lot of hospitals are also experimenting with new forms of payment or models of care such as so-called accountable care organization, or ACOs. For instance, 12 hospitals in Illinois are part of the Centers for Medicare and Medicaid “bundled care” pilot program that’s designed to improve care and lower costs by bundling payments for Medicare patients instead of paying providers for each service a patient receives.

At Mount Sinai Hospital in Chicago, that means heart failure and chronic obstructive pulmonary disease patients will get a more structured post-hospital visit plan. It includes making sure patients properly fill their prescriptions, schedule follow-up appointments and take other steps that should prevent readmissions. Sinai’s heart failure patients have seen a lower readmission rate, from nearly 18 percent before the change to 10 percent after it, said Tina Spector, vice president of clinical integration at Sinai Health System.

Meanwhile, Advocate Health Care has one of the nation’s first and largest ACOs. Advocate, which includes 10 acute-care hospitals and more than 250 other sites, created AdvocateCare, which works with 380,000 patients insured by Blue Cross Blue Shield. “The thinking behind that was that it would better position Advocate for the exchanges in 2014, where there’s going to be much more transparency and cost was going to be a key issue with that, and we’re feeling very good about what we’ve learned and how that’s going,” said Dr. Lee Sacks, executive vice president and chief medical officer for Advocate Health Care.

The Illinois Hospital Association (IHA) says with many of these changes the issue is not if you’ll see an improvement in health care because of changes called for by the Affordable Care Act. The issue is when you’ll see the changes complete. “It’s not going to all magically be in place Jan 1, 2014. This will take years,” IHA spokesman Danny Chun said. “But everyone is working to do it.”For example, data has shown that patients with chronic illnesses like diabetes or congestive heart failure who were part of an AdvocateCare pilot program with Blue Cross Blue Shield and had the benefit of a transition coach— who follows their care upon discharge from the hospital— saw a 27 percent reduction in readmission rates compared to patients who did not have a transition coach.

What’s supposed to change (and what could delay or derail that):

* By Jan. 1, 2014, Americans who can’t afford health insurance or can’t get it because of a pre-existing condition will be able to shop for care in a new one-stop, online marketplace. The biggest unknown is how much the insurance plans on this new website will cost, and that won’t be known until October or later. There’s no guarantee it will be more affordable. Many have speculated that the new requirements for what’s covered, like pediatric and mental health services, could mean higher prices. Subsidies will be available for people whose income is between 133 percent and 400 percent of the federal poverty level to purchase health insurance on the website.

Rosemary Jaffe, for one, is hopeful. Jaffe, 60, works sporadically and has diabetes, heart disease and is a breast cancer survivor. The Berkeley resident lost her health insurance when her husband died.

“I get to the pharmacy, and the pharmacist says, ‘I don’t know what’s going on, but it‘s telling me you don’t have insurance anymore.’ ” Jaffe said. “Sure enough, I had to put out $300 cash for my insulin.”

With her husband’s insurance, Jaffe said she had paid $20 for two bottles of insulin.

Jaffe works only sporadically and will not qualify for Medicare until she’s 65.

Eventually, she determined that COBRA was the cheapest insurance she could find, at $500 a month with a $2,500 deductible. But Jaffe is hopeful that the online marketplace will give her a less costly option.

Even so, the government estimates that roughly 6 million Americans will not sign up for insurance, as we are required to do by the end of 2014. Those who don’t have insurance will have to pay on average $1,200 tax penalty in 2016. Jaffe, of Berkeley, expects that the online marketplace being created by Illinois and other states as part of President Obama’s health reform plan will help her afford less costly insurance. The online marketplace is one of the key provisions of the Affordable Care Act in 2014 and beyond.

* Medicaid is supposed to increase to 133 percent of the federal poverty level (effectively 138 percent, or $15,415 for an individual in 2013, because 5 percent of income is disregarded in determining eligibility). The change is expected to increase enrollment to about 342,000 Illinois residents by 2017, according to the Illinois Department of Healthcare and Family Services. However, the Illinois General Assembly has to pass a bill to change the Medicaid eligibility, so that more Illinois residents can qualify for it next year. Such a bill passed the Senate on Thursday but must clear the House. Gov. Pat Quinn has said he’ll sign it.

If the bill does get passed, Illinois will be gradually expected to pay up to 90 percent for the newly-enrolled Medicare people. The Department of Healthcare and Family Services has said that the $105 million that the department expects to save annually from people that did not previously have Medicaid will more than offset the $573 million they expect the state to pay over seven years.

Jonathan Ingram, the director of Health Policy and Pension Reform at the Illinois Policy Institute, said even if states participate in the expansion, there’s no guarantee doctors will accept the new Medicaid patients. Ingram cited a study published in the journal Health Affairs which found that about a third of doctors nationwide already do not accept new Medicaid patients. Many providers cited low reimbursement rates as the reason. But hospitals that serve large numbers of poor and uninsured patients now have argued that that won’t happen when you consider that uninsured patients who go to the emergency room for care often don’t have insurance at all, so those costs are swallowed up as charity care now. At least with Medicaid, they’ll get some of that back.

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