Health Care Reform: What Does It Mean For Me?

We’ve all been hearing a lot about health care reform and the big changes that are upon us, but many of us are understandably overwhelmed by it all. So what is the chatter really about? What are these changes, and what do they mean for you?

First of all, let’s clarify that health care reform, Obamacare, and the Affordable Care Act are all the same thing. They refer to a set of changes that began in 2010 and will be implemented in a larger way starting January 1st, 2014. The Affordable Care Act specifically refers to the Patient Protection and Affordable Care Act (PPACA), an extremely long and complicated law that is considered the largest revamp to American health care since Medicare and Medicaid became a reality 50 years ago.

So how has the PPACA affected the health care system? Many changes have already taken place. A few notable benefits and provisions already upheld by the Act include:
* For patients on Medicare Part D, falling into the “donut hole” initiates discounts on certain medications to help offset increased costs. For example, patients in the “donut hole” get a 52.5% discount on brand and biologic drugs, as well as a certain discount on generic drugs. Based on a government timeline, the “donut hole” will be fully closed by 2020.
* Plans that cover children can continue to cover them until the age of 26. Children can join or remain on their parents’ plan regardless of where they are living or marital status. They can also stay on the plan even if they are not financially dependent on their parents, and if they are eligible to enroll in their own employer’s plan. Previously, most plans only covered children until age 18 or graduation from college.
* Preventative care and screenings are now largely covered for those enrolled in Medicare Part B and many other plans. This includes yearly wellness visits, mammograms, diabetes screenings, immunizations, and more.
* Those with pre-existing health conditions, considered “high risk” by many private plans, who have been uninsured for at least six months are eligible to buy temporary insurance through the Pre-Existing Condition Insurance Plan (PCIP). This will further expand on January 1st, 2014, when these Americans will get access to plans without discrimination based on pre-existing conditions.
* Insurance companies can no longer take part in what used to be the common practice of re-examining patients to find reason to cancel or rescind their coverage, often due to minor errors made while applying. Patients are now legally protected to keep their coverage as long as they continue to pay their premiums.
* Insurance plans cannot place caps on the amount they will cover over a lifetime. In addition, coverage limits can be no less than $2 million per year.

By October 1st of this year, each state was required to have an insurance “exchange” where individuals and small businesses can shop an online marketplace for private plans available in their area. The exchange allows people the ability to evaluate provider networks and prescription coverage and will eventually provide quality ratings. Individuals may also receive subsidies based on household income if they shop for a plan through this exchange. These subsidies will generally be available to those who fall between 100% and 400% of the federal poverty level and can be immediately applied to lower monthly premiums. You’ll be able to find out what kind of subsidies you qualify for once you complete the application.
Wondering where you can access your state’s marketplace? Visit to get started.

On January 1st, 2014, most of the Affordable Care Act’s changes will take effect. Some of the biggest changes include:
* Health insurance will be required for everyone. If you don’t get a plan, you will be required to pay a penalty. In 2014, this fine will start out at $95 per person, $285 per household, or 1% of income — whichever is greater. These penalties will increase significantly in the following years. (Certain specific exceptions to this mandate exist.)
* Insurance companies must sell to everyone. You cannot be excluded due to pre-existing medical conditions.
* Individuals may not be charged differently for coverage based on gender. Men and women must be charged the same.
* There will no longer be annual caps to health care coverage provided to individuals.
* All plans will provide coverage for a list of “essential health benefits” from a set of ten categories. These include ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; rehabilitative and habilitative services and devices; laboratory services; preventive/wellness services and chronic disease management; prescription drugs; and pediatric services.
* There will be expanded coverage for substance abuse services and mental health for most plans.
* While expanded Medicaid coverage will roll out across the country as part of the Affordable Care Act, several states (including Wisconsin) have elected to opt out of this expansion.

You might still be confused about what options are available to you, and what your coverage could look like in the near future. Your best move depends on various factors such as household income and prescription coverage needs. A useful tool to help you start figuring out how the Affordable Care Act affects you is the AARP Health Law Answers site, available at To read more about the federal timeline for the rollout of the Affordable Care Act beyond 2014, visit And, as always, Community Pharmacy staff are also available to answer questions and point you to further resources.

Dalia Saleh was born and raised in the great city of Madison, and is currently finishing her final year at the University of Wisconsin-Madison School of Pharmacy.