Major Health Reform Changes Effective in 2012

The Supreme Court’s ruling is the most important action, but many other programs have also begun.


The U.S. Supreme Court's action upholding the constitutionality of the healthcare reform was the biggest health reform change of the year. Although it certainly was not part of the law, the court's decision fundamentally changed the outlook for Medicaid, one of the law's most significant provisions.


By ruling that the law's enormous expansion of Medicaid services to lower-income Americans was a voluntary decision left up to each state, the opinion written by Chief Justice John Roberts created a new series of decisions and potential obstacles for extending health coverage to millions of Americans. The law's Medicaid expansion is linked with access by other lower-income persons to private insurance through the law's creation of state insurance exchanges. So, their future also faces uncertainties.

Despite these health reform questions, other key provisions of the law continued to take effect this year. Here are some of the major changes and expansions.

Accountable care organizations. Healthcare critics have long complained that our insurance system pays doctors for performing health procedures, not for providing healthy outcomes. Accountable care organizations (ACOs) are being tested to provide the types of outcome incentives needed to improve care and possibly reduce costs. Physicians, hospitals, and other healthcare providers can create new care groups to coordinate patient care and share in any cost savings. As of July 1, the U.S. Department of Health and Human Services (HHS) said more than 150 ACOs had been set up around the country, and that nearly 2.5 million Medicare beneficiaries were involved in these early pilot efforts.

Women's preventive health benefits. In August, health insurance plans were required to add eight new women's health benefits to the existing list of 14 other benefits already required. These benefits are free, meaning they involve no co-payment or co-insurance, and women need not have met their plan deductibles to use these free services.

Here are the eight new covered benefits:

• Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies for pregnant and nursing women.

• Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortion-inducing drugs.

• Domestic and interpersonal violence screening and counseling for all women.

• Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes.

• Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women.

• Human Papillomavirus (HPV) DNA test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older.

• Sexually Transmitted Infections (STI) counseling for sexually active women.

• Well-woman visits to obtain recommended preventive services for women under 65.

Here are the 14 older covered benefits for women:

• Anemia screening on a routine basis for pregnant women.

• Bacteriuria urinary tract or other infection screening for pregnant women.

• BRCA [BReast CAncer] counseling about genetic testing for women at higher risk.

• Breast cancer mammography screenings every 1 to 2 years for women over 40.

• Breast cancer chemoprevention counseling for women at higher risk.

• Cervical cancer screening for sexually active women.

• Chlamydia infection screening for younger women and other women at higher risk.

• Folic acid supplements for women who may become pregnant.

• Gonorrhea screening for all women at higher risk.

• Hepatitis B screening for pregnant women at their first prenatal visit.

• Osteoporosis screening for women over age 60 depending on risk factors.

• Rh [Rhesus factor] incompatibility screening for all pregnant women and follow-up testing for women at higher risk.

• Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users.

• Syphilis screening for all pregnant women or other women at increased risk.

New consumer health coverage reports. This month, consumers began receiving a new type of standardized report explaining their health insurance. This seemingly modest accomplishment is actually a big deal. For the first time, different health insurance plans will have to present their coverage details in the same format and using the same language. Consumers thus will be able to accurately compare different health insurance plans.

All reports, for example, must answer these eight questions: 1) What is the overall deductible? 2) Are there other deductibles for specific services? 3) Is there an out-of-pocket limit on my expenses? 4) What is not included in the out-of-pocket limit? 5) Is there an overall annual limit on what the plan pays? 6) Does this plan use of network of providers? 7) Do I need a referral to see a specialist? 8) Are there services this plan doesn't cover?

Medicare independence at home demonstrations. While only a test, the government's support for providing home healthcare to seniors could evolve into a major win for the nation's growing "aging in place" movement. Most consumers would prefer to stay in their homes as they get older. Healthcare providers also are looking to provide more cost-effective solutions than those provided at nursing homes and expensive assisted living facilities. The Independence at Home trial has enrolled 19 medical practice groups around the country. They've agreed to provide extensive in-home care to roughly 10,000 seniors with multiple chronic conditions. The pilot's goal is to improve the health of these patients and also save money compared with the expense of repeated hospitalizations. If successful, the practice groups would receive some of these savings as bonus payments.

Twitter: @PhilMoeller