DiVenere: The insurance reforms in the new law are very important to women and to ObGyn practices. In fact, the prohibition on preexisting conditions was a top priority of ACOG’s “Health care for women, health care for all” campaign, and Congress included this provision with women’s health in mind.
Many members of Congress were shocked to learn that it was not unusual for insurers to deny coverage to women who were pregnant, who had had a previous cesarean delivery, or who had been the victim of domestic violence at some point in their history. In fact, almost any medical history, genetic information, disability, or current health condition was grounds for denial of coverage.
Women were also often charged higher premiums than men for the same coverage. And insurance companies would sometimes require waiting periods for coverage—sometimes as long as 9 months.
All of these practices are outlawed by the health reform law, which prohibits plans from using preexisting condition exclusions to deny children coverage as of September 1, 2010 and adults as of January 1, 2014. Beginning on January 1, 2014, women cannot be denied coverage due to pregnancy, previous cesarean delivery, or domestic violence, or medical history, among many other reasons.
Effective March 23, 2010 and ending January 1, 2014, a high-risk pool insurance program has been created for people who have been uninsured for 6 months and who have a preexisting condition. Funding for the temporary risk pool is capped at $5 billion.
Insurers in the small and individual markets and in the exchanges cannot discriminate on the basis of medical history or other variables; may only charge limited premium differentials for age, family size, and smoking, but not for gender; and cannot mandate a waiting period longer than 90 days.
Insurance plans that were in existence before enactment must comply with reforms on waiting periods; lifetime limits; rescission; extension of dependent coverage; uniform explanation of coverage; and loss ratio reporting and premium rebates. Group grandfather plans must also comply with restrictions on annual limits and preexisting conditions.
All these protections should benefit ObGyn practices by ensuring coverage and continuity of care for their patients.
7. What happened to tort reform?
OBG Management: No tort reform was included in the law. Why not?
DiVenere: The law authorizes HHS to award $50 million over 5 years, up to $500,000 per state, to develop, implement, and evaluate alternative medical liability reform initiatives that meet several specific criteria. Medical liability protections under the Federal Tort Claims Act are extended to officers, governing board members, employees, and contractors of free clinics.
We at ACOG were very disappointed that Congress didn’t take a serious step toward medical liability reform in this bill. Liability reform was one of ACOG’s five essential elements of health reform, and its absence from the final bill was a prominent reason why we ultimately “reluctantly opposed” passage. We, and the rest of the House of Medicine, were clear that health reform wouldn’t work without meaningful medical liability reform.
ACOG supports caps on noneconomic damages and other reforms in California and Texas law. We also support testing alternatives, including health courts, alternative dispute resolution, “Sorry Works!” programs, and birth injury compensation funds. But this part of the health reform law requires that tests be linked to patient safety, an association that is impossible to establish in cases of neonatal encephalopathy. The law also requires that patients be allowed to opt out of a system if they choose to go to court. Both of these requirements hamper the development of meaningful alternatives for the ObGyn specialty.
8. Is the system repairable?
OBG Management: Can the US health care system be fixed in one fell swoop?
DiVenere: ACOG pursued two integral missions in reform efforts: improving women’s health and advocating for practicing ObGyns. Our mission in women’s health included guaranteed maternity care, important insurance reforms, and direct access to ObGyns. Our mission in regard to practicing ObGyns included the protection of ultrasonography, the reform of medical liability laws, and repeal of the Medicare sustainable growth rate, along with an array of other issues, all of which were shared by the entire House of Medicine.
We see these missions as integral; Congress saw them as separable. We were largely successful on the women’s health side of the ledger. But Congress responded to the House of Medicine issues with little interest.