What does the Affordable Care Act (the ACA, also known as “Obamacare”) mean for people with diabetes? ACA makes some changes that should help people with diabetes, and some that maybe aren’t so good.
I’m not talking about ACA’s long-term effects on the health-care system or the economy. We’re just talking about immediate impacts on people with diabetes. The most important positive is that plans will no longer be allowed to deny coverage because of diabetes.
According to the American Association of Diabetes Educators (AADE), “Starting in 2014 job-based plans and new individual plans aren’t allowed to deny coverage, charge more, or refuse to cover treatments due to a pre-existing condition such as diabetes.” Many readers have probably been denied coverage in the past. Have you noticed a difference with ACA?
Another good thing: ACA requires “free preventive care” from most plans. This includes diabetes screenings for adults with high blood pressure and for pregnant women. It also requires “medical nutrition therapy” for people with diabetes. But the rules vary by state. What has been your experience?
AADE believes that diabetes self-management training (DSMT) will be more readily covered under ACA, but we don’t know the exact status of DSMT yet. How much training will be covered, and how much will insurers pay?
In theory, all plans have to provide basic levels of coverage and quality to be sold in the government’s “insurance marketplaces.” Most experts think this is a good thing, but some people are miffed. The coverage they have had for a long time does not meet government standards and is no longer available or is at least are harder to get.
A major negative for young healthy people (though not for people with diabetes) is that they are being forced to buy health insurance or pay a penalty. For millions who don’t use health care, whether because they are healthy or because they can’t afford it, ACA adds a financial burden they don’t want. That’s why single-payer coverage like Medicare would be so much better.
Because ACA gives government subsidies for buying insurance, your premium costs could be $60 a month or even less. But low-cost plans come with high deductibles, often in the range of $5,000 a year or more. So for most people, they are only useful in catastrophes like a motor vehicle accident. For someone with diabetes, basic maintenance and care won’t come to $5,000 a year. But if there are complications, you could reach that figure pretty quickly. So you might need to pay higher premiums for better coverage.
The American Diabetes Association (ADA) was a strong supporter of the ACA. On their website, they write that “health insurance is important for people with diabetes to help them access the supplies, medications, education, and health care to manage their diabetes and prevent, or treat, complications.”
ADA gives contact information for each state’s insurance marketplace.
Under ACA, Medicare has started the National Mail-Order Program. It now costs less to have diabetes supplies such as test strips, lancets, batteries, and control solution delivered to your home. According to WebMD, monthly home testing costs could now be as low as $4.50.
Drug costs under ACA should be lower for many people with Medicare. The “donut hole” which suspends coverage after $2,970 has been spent on drugs in a given year, and denies coverage for the next $4,750 of drug costs, is shrinking and will be gone by 2020. After that, drug coverage will be continuous. Good news for people on brand-name drugs and for drug companies.
Things you should know
Writing on Everyday Health, Dr. Ben Hartman lists ten things ACA requires health insurance to cover in diabetes. He suggests that you ask insurers if they cover these things:
• Endocrinologists visits for people with Type 2
• Four endocrinologist visits a year for people with Type 1
• Medical devices (including pumps and continuous glucose monitors if you use them)
• Diabetes self-management education
• Annual eye exams
• Mental health services
• Dental services
• Podiatrist services
• More than one A1C test a year
Cathy Carver, Vice President for Advocacy and Planning at Joslin Diabetes Center in Boston, advises people with diabetes to shop carefully for their insurance. The number of choices can be confusing. Interviewed on the site Type 2 Nation, Carver said,
Focus on three things when it comes to choosing a plan: a plan that doesn’t have high-deductible health insurance, a plan that covers diagnostic tests beyond the preventive screening tests…, and a plan that allows for educational services.
If you’re on insulin, I would ask about device and monitoring equipment coverage as well.
How is ACA working for you? Has it benefited you, or is it causing more problems? Please let us know.