Reading the ACA, part 2

Another ACA post, brought to you while we borrow internet so my host sister can work on TOEFL prep. If this doesn't interest you, please ignore!

July 14, 2014

Day Two. I actually kind of enjoyed my efforts of Day One, so I’m feeling positive going into an amendment to the Public Health Service Act. Let’s get to it!

This is part of that section that prohibits insurers from refusing to provide coverage for pre-existing conditions. From my recollection, this was a huge deal. This part also talks about how insurance eligibility can’t be affected by:

-       health status

-       medical condition (physical and mental)

-       claims experience

-       receipt of health care

-       medical history

-       genetic information

-       evidence of insurability (including conditions arising out of acts of domestic violence)

-        disability

-       anything else the secretary says

These factors also apply to continued eligibility. So if I’m eligible one year and am diagnosed with a chronic condition, my insurer can’t boot me the next year.

I think the domestic violence notation is particularly interesting. I suppose this means that if someone experiences intimate partner violence and can’t access her or his home to get insurance information, she or he can’t be determined ineligible. Does that seem right?

Page 91 includes talk about wellness programs. They’re not allowed to be “a subterfuge for discriminating based on a health status factor” or “highly suspect” in their methods. I’m digging the sinister language. SUBTERFUGE.

Some kind of 10-state demonstration of wellness programs should have started by July 1 of this year. Or a demonstration of states applying the provisions to existing health-promotion programs? I’m not entirely clear on what’s being demonstrated on p. 93.

Bronze, silver, gold and platinum plans: These designations refer to how much the health care benefits are worth (compared with the actual cost of services). For bronze it’s 60 percent, for silver it’s 70, gold is 80 and platinum is 90. From what I can tell, catastrophic plans are allowed if you meet certain criteria (younger than 30 and poor, it appears).

Abortions: not paid for by federal funds, ever. It looks like insurance companies aren’t required to pay for them, but I need to verify with section 1303 and the “special rules.” I know the U.S. pays for them for military members in case of rape. I’m not sure what the rest of the rules are. But as always, in general, no abortion funding.

It looks like states can make their own abortion rules for community health insurance plans, as long as no federal funding goes to them.

Something funny is happening on page 124. This is an amendment about optional services, and it says the secretary, when estimating basic costs, can’t take into account “any cost reduction estimated to result from such services, including prenatal care, delivery or postnatal care.” What I’m getting is that the secretary isn’t allowed to look at the future benefits of having insurance coverage for these “extra” services. Right? My brain flagged this because it seems to suggest that even when there’s good scientific evidence about future benefits of investing in care now, the government can’t calculate them in looking at costs of service.

BUT this is referring to actuarial costs (remember how “actuary” is always the No. 1 job on those “best jobs” lists?), so maybe this is more about accounting rules than public health.

As everyone probably knows, these exchanges are called American Health Benefit Exchanges. Another program exists to help small businesses, the Small Business Health Options Program (SHOP, naturally).

Note: insurers aren’t allowed to market their plans in such a way that would discourage people with significant health needs from enrolling. Insurers are also supposed to include providers in their network who serve low-income, medically underserved people. Sounds like a good thing.

Also, the much-talked-about government portal for insurers is supposed to allow us to compare plans based on ratings by those enrolled.

Plans should have annual enrollment periods (with exceptions), as employer-provided insurance typically does. If you’re an American Indian, there are special monthly enrollment periods for you.

Exchanges have to be government agencies or nonprofits established by states. I’m trying to determine whether there are other examples of the latter bit. Is it common? What other nonprofits are established by states?

Dental insurers are allowed to offer their plans through the exchanges, as long as they provide pediatric dental benefits.

Several sections have discussed “child-only plans” for those younger than 21. I think insurers are required to provide these plans, but I’m not sure why. So parents have to get full insurance for their kids even if they themselves qualify for catastrophic? Must investigate.

State power: States can require their insurers to provide additional benefits, but they have to work to defray the cost to the consumer.

The health exchanges are supposed to be self-sustaining as of Jan. 1, 2015.

On p. 144, the measure states that health exchanges “shall not utilize any funds intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of Federal or State legislative and regulatory modifications.”

That’s kind of specific, right? I totally feel like government agencies would justify using their proceeds on “staff retreats.” And I wonder what determines “excessive executive compensation”? I suppose you’d have to be called out on this to get caught. Also, the exchanges are supposed to report “monies lost to waste, fraud and abuse” on their Internet websites.

Health plans must justify premium increases before they’re implemented, and they have to “prominently post” the increases on their websites.

If you’re in jail or in the U.S. illegally, you’re excluded from all of this.

OK, that’s all for today! I wanted to hit 80 pages since I could feel my momentum waning. There was some interesting stuff today, though I wouldn’t call any of it surprising.

We’re ending on p. 161, at “Sec. 1313. Financial Integrity.” Are you as excited as I am? (Here’s a preview: exchanges are supposed to do accurate accounting. THE FUN NEVER STOPS.)

Reading the Affordable Care Act

OK, so here's a project I've started. It's not related to Peace Corps. Several weeks ago, I decided I wanted to read the Affordable Care Act. I'm writing as I go, reflecting on what I read and trying to understand it. I'll probably embarrass myself with my lack of understanding, but what the hell?

If anyone reads this, I might give it a blog of its own. 

Here goes nothing. This was Day One:

July 13, 2014

I’m going to read the Patient Protection and Affordable Care Act.

I’m not a doctor, a politician or a policy wonk. I have a master’s of science in public health, but I’m mostly a normal person (and journalist). I’m probably going to misunderstand a lot of it, but I’m going to do my best.

I remember hearing pundits talk about how so many politicians haven’t read the act. It is long. The version I downloaded, with amendments, is 2,409 pages. I imagine the proper way to read it is to read the actual act and then return to the top and read the amendments. I’m not going to do that. I’m just going to read it all the way through. That might muddle my understanding of the document, but I think I’ll manage to get the gist.

Or maybe it makes more sense to read the amendments first, rather than reading a version that was later updated. I haven’t even scrolled through to see whether amended sections are struck through.

Also, I’m in a hut in Swaziland in southern Africa, a month away from finishing a two-year stint as a volunteer. I have a lot of down time. I will use this time to read the Affordable Care Act and to write about it here. I am not speaking on behalf of anyone but myself. Also, I don’t have great Internet access in my hut, so chances are that I won’t always be able to look up things that confuse me. I’d appreciate it if you’d cut me a break if I muse over something I could have just Googled.

If I misinterpret wording or if you disagree with me, please feel free to call me out. This is just an exercise in which a normal American Person tries to read and understand an important document produced by the American Government.

Let’s get started!

---

I’m 11 pages in, and I’m still on the table of contents, with its titles and subtitles.

Stuff I’m interested in learning more about:

-       Public health initiatives such as data collection about health disparities

-       Community transformation grants

-       Medicaid coverage for freestanding birth center services

-       School-based health centers

-       Reasonable break time for nursing mothers

-       Scholarships for health professionals

-       Spending for Federally Qualified Health Centers (FQHCs)

-       Limitation of excessive remuneration paid by certain health insurance providers

-       Additional hospital insurance tax on high-income taxpayers

-       Excise tax on elective cosmetic medical procedures

-       Indian health care improvement

Stuff that gives me pause:

-       Termination of provider participation under Medicaid if terminated under Medicare or other state plan (If a state dumps Planned Parenthood, for example, the federal plan must also do so for Medicaid recipients?)

-       Inclusion of cost of employer-sponsored health coverage on W-2 (My health care costs are considered income, which could mean I’m taxed at a higher rate?)

-       Additional requirements for charitable hospitals (This is under revenue offset provisions. What does it mean?)

Part of the ACA requires summaries of benefits and coverage to be presented in a uniform format that’s four pages or less and printed in at least 12-point font. I assume they talked to insurers about whether this was feasible. I think it’s awesome. I sure as hell can’t remember ever reading more than four pages of a document about my insurance benefits. But I’ve been lucky (read: healthy or lazy) enough to not need to read the fine print.

UCR fees = usual, customary and reasonable fees

The ACA requires every hospital to publicly release the cost of standard charges for items and services. TRANSPARENCY FTW.

Every state has to have an ombudsman. Love me some ombudsmen. This is who I’ll contact if I’m looking to get some health care when we return to America.

There’s a lot of talk of Internet websites. To the Internet website! I require informations!

Insurers have to submit justifications for “unreasonable premium increases” to the state and feds BEFORE they increase the premium. They also have to post it online (see Internet websites for details). I’m sure the ACA elaborates on “unreasonable” somewhere – in Section 2794. This section is called Ensuring That Consumers Get Value for Their Dollars, which I am all about. It also suggests that insurers who (this is America, so they get to be “who”) have a pattern of increasing premiums “unreasonably” could get booted from the exchange.

Subtitle B is “Immediate Actions to Preserve and Expand Coverage.” I’m going to read it, but since it’s irrelevant – I believe this is all the stopgap measures that were put in place between passage of the act and 2014 – I probably won’t have much to say about it.

Basically, if you were in a high-risk pool, you should have transitioned to coverage from a health exchange by Jan. 1 of this year. Did that happen? I hope so.

By Aug. 1 of this year, the Treasury Secretary should have notified any insurers that have been assessed a penalty (p. 77). I’m sure this is public information. Just, y’know, FYI. I suppose I’m not sure whether the government would update its Internet website to reflect this in real time.

Session one: pp 1 to 80, started with “December 24, 2009” and stopped at amendments to Subtitle C – Quality Health Insurance Coverage for All Americans

Helping Sakhile

Sanibonani!

My host sister, Sakhile, has been selected for a program called Africa's Tomorrow. It helps African girls get through the hurdles involved with applying to and attending college in America. Right now she's preparing for the TOEFL, which she must pass in order to be accepted. It tests how well she comprehends English. If you want to help pay for it, go here and scroll down to Sakhile from Swaziland. Any help you can provide would be greatly appreciated.

She wants to study dentistry. I don't know the statistics, but I know dentists are few and far between in rural Swaziland.

If you can help her out, it would be huge.

Siyabonga kakhulu! (We thank you so much!)

Goodbye, good luck, give me a job

Sanibonani, all.

Sooo, here we are. I have less than a month left here, and it's becoming a whirlwind already. My host sister made it through step one (of a MANY-step program) to go to college in America. That'll mean the TOEFL for her and lots of preparation help from me. There's supposed to be another volunteer replacing me in my village, so I'm hoping that volunteer can help shepherd her the rest of the way. I'll be fundraising to help defray the cost of the exam soon. As of now, I'm paying for it.


I'm preparing to leave and getting ready to say goodbyes. We had one of our last girls empowerment club meetings last week. I had been waiting to talk about reproductive health until I felt that the girls were comfortable with me. This was the time.

We covered the whole female reproductive system, and they asked a few questions. But then I brought out my trump card: the question box. The girls bolted for the scrap paper and started writing the questions they were too embarrassed to ask aloud:

- Will my period hurt?
- How old will I be when I get it?
- What if I have my period, and my mother wants to see my vagina?
- What happens if I have sex while I'm still young?
- Can I get pregnant if I have sex while I'm menstruating?
- What do babies eat inside the womb?
- How does the baby get out of such a small opening?

We had more than 20 questions from our group of 24 girls. As we answered them, girls would run up and put more questions in the box. It was absolutely amazing. These girls are young, 11 to 14, so I didn't expect them to have much information about this yet. But I was thrilled that the other club leaders and I could help explain this confusing process that is adolescence. It was so gratifying.

The next week, my friend and I taught a great HIV and STI session at the high school, where the kids peppered us with questions:

- How long does HIV survive outside the body?
- If a woman is HIV-positive and has an HIV-negative baby, what is she supposed to feed it if there's HIV in her breast milk?
- How can an HIV-positive woman and an HIV-positive man make an HIV-negative baby?
- If one person has HIV, and the other partner doesn't, will they always get infected if they have unprotected sex?

Afterward, the teachers who were present said they'd also learned a lot. And my friend, who had been hesitant before, eagerly took my HIV materials and lesson plan so she could reuse them.

It's been a gratifying couple of weeks.

I've also gotten deep into the job hunt, which is nerve-racking and a little terrifying. But Jack and I know we'll make it through it. Who wants to hire us? Anyone?

Salani kahle, all!

Branding day

It's always a bit of an adventure when my host dad approaches me on a Sunday afternoon. It typically means we're about to talk Monday-morning cattle ops. This past Sunday, that was the case.

"We have to burn them tomorrow," he said.
"Oh, like brand them?"
"Yebo."

Babe showed me where the brands go. On the back left thigh is our dip tank number, 401. On the left shoulder is the oval with four evenly spaced lines poking out -- the Swazi shield. They use both so that if a cow is stolen and taken into South Africa (or Mozambique, I suppose), they know it's a Swazi cow. Then they know it came from our dip tank, and I think there are records that Babe would be able to use to claim a cow as his own.

Babe and my host brother rounded up the cows and counted out the number that needed branding. They brand each year, but this was the first year the farmers were handling it on their own. Government vets helped the previous two times. The count yielded 55 cows with hides that required the iron touch.

I asked Babe what time we'd need to leave in the morning.

"Four, unless there is no moon. If there is no moon, the cows can't see, and they won't go. Then we would wait."
I looked up at the overcast sky and decided to set my alarm for 4:15.

I heard Babe's pickup start after I hit snooze the second time. I dragged myself up and into my clothes. We loaded the firewood for branding, and Babe sent me out to wait for the cows to leave the kraal. He had his truck, and I, foolishly, decided not to bother with a headlamp.

It had been humid when I awoke, but the morning was growing colder as we stumbled through the bush. Babe kept behind us, headlights on the animals, as I tried to avoid stepping off into an unexpected creek bed.

"Be careful! You will break your legs!" he yelled out the window.

I strained my eyes to make sure no cows were wandering off, but it was as dark as I've seen it here. No town lights permeate this route, from the rural homestead to the even more rural cow-dipping channel.

I stumbled repeatedly, scraping my bare shins against the thorn bushes.

We arrived without my noticing. Babe told me to be careful of the rocks to my right, and I realized the cattle were pressed against the wooden fence near the dip area. Two fires were going nearby -- a big one for the branding and a small one to warm the children who had come to have their goats counted by the government vets.

We stood, waiting silently, while Babe went to go pick up a man to help us. It was clear that I wasn't up to whatever challenges branding might bring.

An hour passed. At about 6:30, the sky lurched into gray light. The chill remained.

We couldn't see anything happening inside the kraal where the men were branding. I could hear an urgent moo every now and again, but no chaos broke out. At about 8 a.m., it was our turn to shuffle in. The cows, sensing what was going on, took the opportunity to make a mad dash. Hundreds of cows were clumped behind us, and my brother Senzo had to bang his way through the crowds, picking out Babe's bunch.

The excitement started after we hustled the cows into the kraal. Branding required four to six men per cow (and one woman). The first man tried to loop a rope over either the thorns or the back legs. Once he caught one side and wrestled the cow down, he and others tied the head to the back legs, tied up the other legs and placed another rope around the cow's midsection. Someone had to hold each of these -- head, two sets of legs, belly. Once they had the cow in place, left side up, they yelled: "inombolo!" (number!) and then "lihawu!" (shield!). The men with the 6-foot branding irons would haul them over from the fire -- on the other side of the kraal fence, for safety -- and press the flesh. The cows would jerk and wail while clouds of smoke rose from their bodies. The smell, at first nauseating, reminded me of a hair salon.

After each brand was finished, a woman with a plastic dish would paint antiseptic goo on top. The cows would get up and go about their business, often unhappily.

At one point, a white cow with red spots and wicked-looking horns charged up after his branding, furious, kicking at people and butting at other cows. I was daydreaming in the kraal entryway at this point.

"HIT HIM! HIT HIM HARD!" Babe yelled at me from across the kraal.
"What?! Which one?" I flung my cow-whacking stick at every nearby animal.
Senzo bolted over and started in on the cow, driving him and the others away across the enclosure.
"Hit him hard next time," Babe said. "Don't try to be friends with him."

I hadn't witnessed the precursor to this moment, but Senzo later told me the cow wanted to kill me.
"If you had black skin like me, he would have killed you. But you are white. He thought you were an animal. He was confused."

The process took nearly three hours. I wasn't doing any of the hard work, of course, just making sure no cows entered or left the pen. Once Babe had burned his 55th cow, we were ready to drive them home. He stuck around to help the men who helped him. I, satisfied with my first (only?) cattle-branding experience, went off in search of warmer clothes and a liter of coffee.

AGOA and Swaziland

Swaziland is about to enter an interesting, and probably challenging, period. The United States has revoked its eligibility for African Growth and Opportunity Act benefits. What this means is that as of Jan. 1, Swaziland won't have duty-free access to the American market for its manufactured goods.

The U.S. government says Swaziland hasn't done enough to protect workers' rights, specifically freedom to assemble and organize.

There's been a lot of discussion in the Swazi papers about it. Some factory operators expect to lay off workers or to close entirely. It's been difficult to get a sense of the real financial impact. Jack and I haven't seen specific reporting on how much costs will increase or how expensive it would be for manufacturers to actually pay the duties involved in shipping goods to America. We're also not sure what percentage of goods manufactured here end up in American markets.

Regardless, people seem nervous about what this change will mean in Swaziland, where unemployment is already above 40 percent.