September 2012 - Susman
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Westchester, CA

Located in the eastern portion of the Del Ray hills, Westchester, CA is bordered by Culver City, Plays Vista, Inglewood to the east, and El Segundo to the south. To the north is Ladera Heights. The southern part of Westchester is taken up by Los Angeles International Airport. According to the 2010 US Census, Westchester had a population of 39,000.

Westchester’s crime rate is lower than other parts of Los Angeles, which results in lower insurance rates. The presence of both fire and police stations in the area also help keep insurance rates lower than other parts of Los Angeles. The average listing price for a home in the Westchester area is $676,154. Homes are predominately single-family dwellings, with three bedrooms and at least two bathrooms.

Westchester is the home of Loyola Marymount University, as well as the Otis College of Design. Its most famous business resident was Howard Hughes. The street named Runway Road was originally part of Hughes’ large airport and manufacturing conglomerate, which as also the home of Hughes’ wooden airplane, the Spruce Goose. Hughes’ money and manufacturing was the backbone for much of what exists as the movie industry.

For a map of the Westchester area, click here.

Westchester, California
Westchester, California

The New Health Care Law: The Affordable Care Act

Introduction

Despite that it continues to be referenced as “new,” its derogatory nickname of “Obama care” and the controversy regarding its legality until the Supreme Court upheld the law’s constitutionality in June 2012, the Affordable Health Care Act (ACA) has been the catalyst behind enormous changes in the American health care system since it was enacted in 2010. An enormous document in both length and scope, the law — known formally as The Patient Protection and Affordable Care Act (PPACA) — was organized into ten sections, each termed a “title,” and each designed to address a specific issue of the American health care system. The law was also designed to phase in changes over a decade long time frame in order to allow necessary public education about the new system and adaptations of the existing system to the required changes to take place from New York to California. Even as the unsuccessful lawsuit, National Federation of Independent Business v. Sebelius, began in the court system, the Affordable Care Act had already begun to make changes as to how Americans receive health care, how insurance companies can treat customers and how to expand the availability of health care to more citizens.

Summarization of Titles or Scheduled Changes By a Timeline? How Best to Understand the ACA & Changes to Your Medical Care

Few of us have the time to read the Affordable Care Act law in its entirety, as did medical physician and financial planner, Dr. Carolyn McClanahan. In her research for a July 2012 Forbes.com article, “Cliffs Notes Versions of the Affordable Care Act,” Dr. McClanahan logged 40 hours to read and review the law numbering just under 2,500 pages. Luckily, each of us need not read the entire statute to learn of the law’s benefits, anymore than most of us probably do not read the annual Benefits Manual of our health insurance carrier from cover to cover (should we be so lucky to be covered under a medical insurance plan). As recognized by Dr. McClanahan, an outline review of the ten titles that make up the act can provide citizens with the basic tenets and philosophy of the law. Specific changes can be reviewed under title or via a timeline explanation as they have been scheduled to take place from 2010 to 2020. For those readers without the time, patience or interest in reading more about the details of the program, an interactive visual tool, “Illustrating Health Reform: How Health Insurance Coverage Will Work,” has been developed by The Henry J, Kaiser Family Foundation website, HealthReformKFF.org.

The Ten Titles of the Affordable Care Act & Their Primary Effect(s) on Health Care

The primary effect(s) referred to in the subtitle are either specifically and individually addressed in each of the Affordable Care Act’s ten titles or have been objectively observed to have occurred since early provisions were implemented. Two facts of life must be emphasized when discussing planned change: there are always unintended consequences to formal actions and some logistical details of future ACA interventions have not yet been solidified.

  • Title I: Quality Affordable Health Care for All Americans

Title I of the Affordable Care Act changes the way insurance companies can operate and prohibits some of the ethically-challenged ways in which they treated patient customers under their benefit plans in the past. The three major changes established by Title I include:

  • Insurance companies are prohibited from refusing to provide health care coverage to individuals who have a diagnosed disease or condition, also known as a pre-existing condition. In some cases, infants found to have genetic disorders or congenital malformations through amniocentesis or sonograms were denied as dependents on their parents’ policy even before birth. Cancer-survivors and those suffering from diabetes or other lifelong chronic conditions faced medical bankruptcy when insurers refused to cover them. These issues can affect your medical care and quality of life whether you’re a resident of Beverly Hills or Watts.
  • Similar to the way in which most states mandate automobile insurance, all citizens are required to have medical insurance coverage or pay a penalty “tax” beginning in 2014. According to CNN.com, “In 2014, the penalty will be no more than $285 per family or 1% of income, whichever is greater. In 2015, the cap rises to $975 or 2% of income. And by 2016, the penalty would be up to $2,085 per family or 2.5% of income, whichever is greater.” In addition, there are many exemptions available.
  • Finally, individuals lacking an adequate income can receive financial assistance or subsidies to pay for their premiums and those under the 133 percent poverty level line will qualify for medical care under Medicaid.
  • Title II: Role of Public Programs

Curiously, Title II of the Affordable Care Act is a mix of old model programs and the introduction of a novel, effective and creative type of medical care.

  • Improvements to the way in which public programs such as Medicaid and the Indian Health Services will be implemented to reduce bureaucratic inefficiency and increase these agencies’ accountability to patients and the government for the quality of care they provide.
  • Mandated for both public and private health delivery systems is the expectation of both to adopt the Patient Centered Medical Care Home model, also known as an Accountable Care Organization (ACO). Under this system, patients are expected to have a supervising physician or primary care physician responsible for overseeing a team of professionals from all aspects of health care. This style of medicine is holistic, team-oriented, local and provides a more coordinated approach than our current system.
  • Title III: Improving Quality and Efficiency of Health Care

The third Title, Improving Quality and Efficient of Health Care, begins the change in our current per service rendered fee-based medical system toward a graded, results-driven system where success outcomes are rewarded with significantly higher reimbursement rates. Per the usual routine with health care administrative changes, the program begins with Medicare requirements to implement the changes within a certain timeframe. Private insurers almost always follow suit. A prerequisite to measurement of Title III compliance is continued supervision of a patient — presumably by Medical Care Home team — and statistical evaluation of outcomes such as hospital readmissions, death, nursing home admissions or other measurable events. As with many other aspects of the Affordable Care Act, quality will be measured — and Medicare reimbursements determined — independent of a patient’s income. An undesirable result is an undesirable result in any area of Los Angeles, be it Santa Monica or Brentwood.

  • Title IV: Prevention of Chronic Disease and Improving Health

Title IV of the ACA addresses our health care system’s poor approach to disease prevention. Although this Title was one of the least discussed during its development, it has had one of the greatest effects on the insured population to date. Because so many of the now voluntary suggestions were scheduled to become mandatory within a few months, Medicare and many private carriers have already adopted them. Included in this aspect are annual medical exams free of any charge, copay or deductible, no-cost cancer screenings such as colonoscopies and mammographies and even subsidized or free gym membership for individuals covered by Medicare.

  • Title V: Health Care Workforce

Title V, also known informally as “the Jobs Bill,” attempts to reconcile our national need for primary care providers — beginning with primary care physicians PCPs — to head those Medical Care Home Model teams. A shortage of nurses has already been apparent for a decade and a need for home health workers will rise exponentially as Boomers age and more care is team-supervised at home for less cost, fewer complications and improved efficiency. This aspect of the bill requires coordination of educational programs, the public university system, appropriate governmental entities and public and private health care providers to approach any type of solution.

  • Title VI: Transparency and Program Integrity

The sixth Title of the Affordable Care Act is a nice way of saying that we need to eliminate health care system fraud, abuse and continued and uncorrected errors that waste millions of dollars, or more, each year. A fake rear-ender clinic in Westwood ultimately costs us and our families the money spent to close the claim, Allstate or State Farm or Farmer’s or Geico doesn’t simply absorb the loss. Progress with this Title requires coordination between the police, health care providers and whistleblowers who have been approached to participate in these scams.

  • Title VII: Improving Access to Innovative Therapy

Title VII will hopefully be the bright and hopeful Title coordinating equal access to expensive or difficult therapies to all patients. Currently, it refers to the work still necessary to improve access to generic drugs. While Dr. McClanahan dismissed this Title with sarcasm, I believe her reaction to stem more from a misunderstanding of the cost of name brand drugs to lower and middle-class households than any purposeful mean streak. It might not even cross the radar of residents of the Pacific Palisades or Malibu that the extremely effective allergy medication Singulair, is not yet available generically as “Montelukast.” But I’ll bet you the usual monthly cost, $50 for 30 pills, that more Topanga Canyon residents are aware of this lack.

  • Title VIII: Community Living Assistance Services and Support

Dr. McClanahan also is also somewhat dismissive of Title VIII of the Affordable Care Act as too unwieldy to work and passed only in deference to the late Senator Edward Kennedy. Yet, articles and blogs consistently report on the use of this Title to maintain people out of institutions and within their homes and their communities. According to a September 11th article on the HealthCare Blog of HealthCare.gov, “Secretary Sebelius announced $12.5 million in awards to Aging and Disability Resource Centers across the country” that very day. The article reports that the Centers are expected to “provide expert counselors to help older Americans and people with disabilities and their family members understand the services and supports that are available to them in their communities, and help them sign up and access those critical services and remain independent.” This is not an unimportant aspect of mental and physical health and social involvement has consistently been linked to decreased mortality and improved quality of life.

  • Title iX: Revenue Provisions

Title IX is where the rubber meets the road. It details how the cost of implementing the new program over a decade-long time frame will be paid.

  • Title X: Strengthening Quality Affordable Health Care for All Americans

Title X is akin to some surrealistic sci fi spy movie. The fact that a repeated title of the first Title sounds like an assignment of ten and some Congressman desperately searching for that 10th intervention! The sad truth that it contains special interest provisions about gun owners’ rights — among other unrelated pieces of data — strongly suggests that Title X should have addressed a solid mental health delivery system in addition to its other interventions.

Conclusions

The Affordable Care Act is a hopeful plan that seeks to equalize treatment between those of different incomes and provide medical care to all citizens of the US. The initial implementation phases will be rocky at times and develop untoward and unintended consequences, which may require correction. However, if the current degree of fraud, waste, mismanagement and monies spent on preventable illnesses unaddressed decades ago could somehow magically appear, the program would probably be making money.

LIMITED ARTICLE-RELATED GLOSSARY

Accountable Care Organization (ACO): A group of health care providers who establish a joint practice to offer complete health care services for their member patients. ACO’s would be paid for health care provided to their member patients based on the “quality and cost” of the medical care provided.

Benefits Manual: A comprehensive manual required by law to be issued annually by health insurance providers to those insured by their plans to explain the terms and limits of their coverage.

Dollar Limits: Refer to a “limit that health insurance companies may put on the amount of care they cover. Once individuals reach that dollar limit, they are required to pay for additional health costs on their own. Insurance companies can no longer put dollar limits on the amount of care they will cover in your lifetime. Annual dollar limits are being phased out between now and 2014.”

Exchanges: State-based markets that would allow uninsured citizens and small businesses to shop for and compare health plans. These markets are scheduled effective in 2014.

National Federation of Independent Business v. Sebelius: The unsuccessful lawsuit challenge to the Affordable Care Act dismissed by the Supreme Court in June 2012.

Pre-existing Condition: An illness or disability that an individual had before enrolling in a health coverage plan. Each state law defines pre-existing conditions differently. Examples of pre-existing conditions are asthma, diabetes and cancer. and congenital birth defects.

Preventative Services: “Health services that help detect and prevent illness. Services may include check-ups, counseling and screenings.”

The Patient Protection and Affordable Care Act (PPACA): (also known as The Affordable Care Act) The US health care delivery system law passed in 2010, upheld as constitutional by the Supreme Court in 2012 and scheduled to continue to phase changes to citizen access to our healthcare system through 2020.

Titles: The means by which the enormous Affordable Care Act is organized into ten sections.