Perhaps you’ve had a mammogram recently, or taken a child for an immunization or consulted with a specialist about a weight problem. Since late 2010, those visits to health-care providers have carried an additional benefit: They’re free. Under the Patient Protection and Affordable Care Act, signed into law 28 months ago and largely upheld in June by the Supreme Court, it’s illegal for insurers to charge consumers a co-payment for a long list of health care services designed to prevent disease.
In fact, while they have been largely overshadowed by the furor over the requirement that everyone carry health insurance, there are many provisions in the law designed to encourage wellness, fitness and prevention. It’s an effort to improve health and reduce the ever-escalating cost of health care.
Some measures have been in effect for nearly two years and escaped cancellation when the Supreme Court preserved the law. Others are on the way. Just last week, the controversial regulations on free contraceptives and other preventive care for women took effect.
A large portion of health-care costs are attributable to preventable disease. Federal statistics show, for example, that more than one-third of American adults are obese — a condition that carries all manner of health risks, such as Type 2 diabetes, heart disease and high blood pressure. The health-care law tilts heavily toward preventive services and developing new prevention policies.
“When you remove cost barriers, people are much more likely to use services, and that’s been demonstrated for many, many years,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation who specializes in health-care reform and private insurance.
The benefits kick in when your health insurance plan changes or is updated. According to the Department of Health and Human Services, 54 million people have received free services under the law that previously would have cost them at least a co-payment.
Most people will feel the greatest tangible impact of the new law where they work. That only makes sense. It’s where most of us get our health insurance, and employers increasingly have been turning to wellness programs to cut costs anyway.
A 2010 study by Harvard University researchers, published in the journal Health Affairs, concluded that “medical costs fall by about $3.27 for every dollar spent on wellness programs and that absenteeism costs fall by about $2.73 for every dollar spent.” It remains difficult, however, to pinpoint which wellness programs produce the greatest bang for employers’ buck.
Beginning in 2014, the health-care law will allow employers to increase incentives for participation in programs that require an employee to achieve an agreed-upon wellness goal, such as giving up tobacco or losing a certain amount of weight. The incentive can be as much as 30 percent of an employee’s insurance costs, and in some cases as much as 50 percent. That is up from 20 percent allowed by law now.
Employers also may continue to offer help that is not tied to outcome, such as subsidized gym memberships, health assessments and nutrition counseling, without limits on incentives.
“What the law is trying to do is give greater incentive to [those who] want to participate,” said Mayra Alvarez, director of public health policy in HHS’s office of health reform.
“Corporate America now understands that a healthy workforce is very productive and beneficial to their bottom line,” said Scott Goudeseune, president and chief executive of the American Council on Exercise.
But the increased benefits are not without controversy. Some experts are concerned that by providing premium discounts to workers who participate in such programs, employers are, in effect, penalizing those who don’t or physically can’t. The law demands that employers provide reasonable alternatives for them, but patient advocates are concerned about how this will be implemented.
Even more worrisome to other analysts is the provision that allows the incentives to be conditioned on the results participants achieve in certain programs. But as long as the program is reasonably designed and not a subterfuge for discrimination, Pollitz said, the law allows it.
Insurers, health-care providers and employee advocates are awaiting regulations that will govern how this provision is carried out.
Under the law, the following health care services, and many others, must be offered free.
Adults: Screening for HIV and other sexually transmitted diseases, colorectal cancer and depression; immunizations; obesity counseling and help quitting smoking.
Women: Screenings for gestational diabetes and cervical cancer; well-woman visits.
Children: Behavioral assessments, body mass index measurements, vision and lead screening.
Seniors: Under Medicare, bone mass measurement, prostate cancer screening, cholesterol and cardiovascular screening, flu shots.
Parts of the law are not targeted at individuals. Congress authorized $12.8 billion between 2010 and 2019 for a Prevention and Public Health Fund designed to help communities improve the wellness of their residents.
The money will help cities, counties and states improve public health facilities, such as laboratories, and train personnel for public health work. The government will launch a major research project to determine which wellness programs work best.
Some of the more unusual work may come out of the law’s Community Transformation Grant program, which to date has awarded $103 million to reduce obesity, improve access to nutritious food and beef up anti-smoking programs.
The state of Maryland is the only local jurisdiction to receive such a grant so far, $1.9 million that it will spend outside the state’s five major population centers.
Working with cities, counties and nonprofits, the state is sending staffers to convince owners of the benefits of constructing smoke-free apartment buildings for the poor (lower insurance rates, easier upkeep) or preserving single buildings or floors as smoke-free, said Donald Shell, director of the center for chronic disease prevention at the state Department of Health and Mental Hygiene.
Other workers are headed into schools to educate principals on the need for recess (healthier, more attentive students) and help them change the fare in vending machines from junk food to more healthful snacks. Still others will work with private businesses to promote walk breaks, health-risk assessments, nutritious cafeteria food and gym subsidies for employees. And some will try to remove community barriers to fitness, such as inadequate bus service that keeps the elderly from senior centers.
Progress can be slow in some areas: Doughnuts are still among the best-sellers for civic groups trying to raise money, Shell said.
“The reality is that people say, ‘If we offer healthy stuff, we don’t make any money,’ ” Shell said.
The number of months the Patient Protection and Affordable Care Act has been in effect.
The number of people who have received free services under the law.
The amount that medical costs fall per dollar spent on workplace wellness programs.
The amount of a grant Maryland received to spend on wellness initiatives.
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