Wednesday, March 31, 2010

Health Reform: Enactment Status of CHADD’s 13 Principles

The Patient Protection and Affordable Care Act is now Public Law 111-148. The Health Care and Education Reconciliation Act (HR 4872) was signed into law on March 30. Through these two pieces of legislation, Congress and President Obama have succeeded in enacting comprehensive health reform.

On August 13, 2009, CHADD issued 13 principles to consider in health care reform. On October 15, CHADD and five national sister organizations (AACAP, ASA, CABF, MHA, and NAMI) issued five principles to consider. The five are a merged and consistent statement with the previous 13.

CHADD’s 13 principles and their enactment status are as follows:

1. Provide health care coverage for all Americans

The Congressional Budget Office (CBO), the financial scorekeeper for the Congress, estimates that health reform will cover 32 million currently uninsured Americans by 2019. However, CBO also estimates that 23 million Americans will remain uninsured by 2019. The 2019 uninsured group includes seven million undocumented immigrants and 16 million who will choose not purchase insurance, despite the individual mandate to purchase insurance.

Health reform requires all Americans to purchase insurance by 2014, with financial penalties assigned to those who don’t. Penalties are $95 in 2014; $325 in 2015; $695 in 2016 and indexed thereafter. However, low-income individuals who would have to spend more than 8 percent of their salaries for health insurance are not subject to the penalty. People who make too little to file an income tax return also are excused ($18,700 for a couple). A number of the young, healthy people may prefer to pay the $95 fine in 2014 rather than purchase insurance. Health-plan enrollment by these individuals would likely increase as the penalty amount increases to $695 (or 2.5 percent of the person’s income, whichever is higher) in 2016. A coalition of state attorney generals have filed lawsuits challenging the constitutionality of the individual mandate.

Health reform expands Medicaid mandatory eligibility to 133 percent of the federal poverty level in 2014 ($29,327 for a family of four). Ninety days after enactment, persons who have no access to insurance because of pre-existing condition exclusions could have their insurance premiums paid by a new “National High Risk Pool.” These pools would terminate upon the enactment of “insurance exchanges.”

Health reform mandates that states establish state-based health insurance exchanges for individuals and small businesses by 2014. Income tax credits would be available for persons with incomes less than 400 percent of the poverty level ($88,200 for a family of four) to purchase insurance.

2. Require “parity” for mental health assessment and treatment, including prohibiting non-discrimination between health conditions

Health reform extends the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (P.L. 110-343) protections to all health plans in the exchanges, as well as all commercial plans currently covered. Mental health and substance abuse benefits, to be defined by regulation, are also part of the mandatory “essential” health benefits package.

3. Prohibit discrimination on the basis of pre-existing conditions

Health reform requires that for plan years beginning on or after six months from enactment, health plans may not discriminate on the basis of pre-existing conditions for children. However, media stories have already identified a conflict between interpretations of this prohibition by insurers and by the Obama administration. Both the insurers and the administration agree that for children offered insurance, the plans must cover pre-existing conditions. The insurers argue that the law does not require them to issue health plan coverage for children with pre-existing conditions. Any children and others denied coverage for pre-existing conditions would be eligible for assistance in the National High Risk Pool to be established within 90 days of enactment.

In 2014, all pre-existing condition exclusions would be prohibited.

4. Prohibit health plans from terminating coverage when people become seriously ill or when they are treated for long-term chronic conditions and eliminate lifetime conditions

Rescissions (the practice of terminating health plan coverage) and lifetime limits are prohibited, effective for plan years beginning on or after six months after enactment.

5. Prohibit exorbitant out-of-pocket deductibles and co-pays

This goal is difficult to define and subject to lots of debate. The Department of Health and Human Services and the National Association of Insurance Commissioners would define by regulation what constitute “unreasonable” premiums, deductibles, and co-pays. There is much debate about the affordability of the premiums and subsidies.

6. Allow young adults to stay covered on their parents’ plan until the age of 26

Effective for plan years beginning on or after six months after enactment, health reform requires insurers to allow young people to stay on their parents’ policies through age 26.

7. Target specific coverage of young adults, particularly those with special health care needs

Not specifically addressed. A new long-term care program, named CLASS, would be created by 2014.

8. Target specific coverage of children, particularly those with special health care needs

Not specifically addressed. A new long term care, named CLASS, would be created by 2014.

9. Require continued affordable coverage when one loses or changes jobs

Health reform requires guaranteed issue and renewal, effective 2014. Individuals and families who purchase coverage through the exchanges will not be stuck with their employer’s health plan or subjected to losing coverage due to loss of job.

10. Include wellness and prevention services

Health reform creates a Prevention and Public Health Fund, which will provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs. The Fund provides mandatory funding, over the fiscal year 2008 level, for programs authorized by the Public Health Service Act, for prevention, wellness, and public health activities including prevention research and health screenings. It is important to note that, for fiscal year 2010, $500 million will be appropriated for the aforementioned initiatives. Additionally, Health reform instructs the HHS Secretary to plan and implement a national public-private partnership for a prevention and health promotion outreach and education campaign to raise public awareness of health improvement across the life span. Health plans are required to include annual wellness visits.

11. Promote integrated primary care with specialty services, including promotion of the “medical home” concept and including consumer-oriented and meaningful use of electronic medical records and personal health records

Health reform creates state grants for community-based health teams to support implementation of patient-centered medical homes and allocates funds to state Medicaid programs to implement such medical homes.

12. Allow consumers a choice of health plans

Health reform establishes state-based health insurance exchanges for individuals and small businesses by 2014. Income tax credits would be established for persons with incomes less than 400 percent of the poverty level ($88,200 for a family of four) to purchase insurance.

13. Include culturally and linguistically appropriate programs that affirmatively address racial and ethnic disparities, including the recognition of disability-based health disparities

Federally conducted and supported health care programs must collect data on race, ethnicity, sex, primary language, and disability status. A population is considered a health disparity population if there is a significant disparity in disease incidence, prevalence, morbidity, mortality, or survival rates or in quality, outcomes, cost, use of health services, or satisfaction with health services compared to the general population. Health plans and health providers are then required, albeit with federal financial assistance, to address these disparities.

Health plans in the health insurance exchanges are to conduct public education activities, including those that are culturally and linguistically appropriate for the needs of the population to be served. Federal grants will be available to promote shared decision-making between patients and professionals including trade-offs among treatment options, patient preferences, and patient values.


While many disagree about the appropriate role of the federal government in health care, the individual mandate, and the financial impact of taxes and fees, people with ADHD and related and co-occurring disorders should directly benefit from health reform. Individuals who have faced discrimination and lack of insurance coverage because of their disability would benefit from health reform. While issues of affordability continue to be confusing and controversial, health reform makes the most significant progress toward universally affordable and appropriate health insurance in generations.