By Elizabeth Simpson
© April 4, 2010
Jane Prinz has been known to split her prescription pills in half just to afford her medications, so she has paid close attention to the national debate over health care.
Will the new law signed by President Barack Obama last month help the 41-year-old Virginia Beach woman?
She's still not sure. Pills aren't the only thing hard to divide.
"It's hard to divide the actual facts from all the rhetoric," said Prinz, who has a neurological disorder.
It's a view shared by many.
There are numerous unanswered questions as the 2,000-plus pages of law get transformed into even more pages of regulation. The region's patients, doctors and hospitals await the details and consequences, both good and bad.
Roughly 1 million Virginians are uninsured. According to the Virginia Health Care Foundation, it's expected that under the new law about one-third will be newly eligible for Medicaid, the shared federal and state insurance for the poor and disabled. An additional 17 percent of the state's uninsured fall between ages 18 and 24, and they could be added to their parents' insurance. And 700,000 are expected to qualify for insurance subsidies, according to the Commonwealth Institute for Fiscal Analysis.
The law will have consequences for the insured as well, and Prinz falls into two critical categories.
She's a member of a Medicare Advantage plan, an insurance program that the new law targets for cuts. That's a move that some insurance experts say will either reduce benefits or increase premiums with the privately managed plans.
Prinz also is in a category of people that the law is expected to help: Medicare recipients who fall into the so-called "doughnut hole." That's a gap in prescription drug coverage that begins when about $2,800 is spent on drugs.
Prinz hit the doughnut hole last year in March, and she's bumping up against it this year as well.
The new law would provide a $250 rebate this year and give her discounts on name-brand drugs beginning in 2011. The gap will start closing next year, a process that will be complete in 2020.
"It's a start, but it's a weak start," Prinz said. "What am I supposed to do for the next 10 years?"
Because Virginia's current eligibility for Medicaid is one of the most restrictive in the country, the state is expected to pick up more new Medicaid patients - 350,000, by one estimate - than many states. Childless, non-elderly adults in Virginia will be eligible for the first time in 2014.
The gateway for the newly insured will be family-practice doctors, many of whom are already swamped.
"This will unveil the shortage of primary-care physicians," said Dr. Christine Matson, chairwoman of family and community medicine at Eastern Virginia Medical School.
Doctor reimbursements for Medicaid patients are less than those for private insurance and Medicare, the federal insurance for the elderly and some disabled people. The health care law will increase Medicaid reimbursements in 2013 and 2014 to bring them in line with Medicare.
Still, many doctors limit their acceptance of that government insurance, too.
Dr. Cynthia Romero, a family-practice doctor in Virginia Beach, said some of her new Medicare patients tell her it took months to find a doctor who would accept their insurance. "I think we'll be bombarded by the volume of new patients looking for care," she said.
Dr. Daniel Carey, president of the Medical Society of Virginia, said the General Assembly made cuts to the Medicaid reimbursement rates in the most recent budget, and that's expected to reduce the number of doctors willing to accept new Medicaid patients.
He said the new law failed to address what doctors see as a flawed Medicare and Medicaid reimbursement formula. As long as doctors and hospitals lose money on patients with those types of insurance, it will be tough to expand the primary care network.
And health care providers are concerned that state legislators will continue turning to Medicaid to seek cuts during budget shortfalls.
"We are holding our breath," said Howard Kern, Sentara Healthcare's president and chief operating officer.
On the positive side, more insured patients mean people will address health issues sooner, reducing costly emergency-room visits and hospital stays. Medicare will also provide free annual wellness visits and prevention plans under the law.
"The most important thing is it moves us toward the idea that all citizens should have access to health care," said Matson, of EVMS. "It's been embarrassing and tragic not to have had that in place."
Meghan McNamara, 23, of Norfolk hopes the law will help young adults such as herself. She is uninsured because she is working on a short-term basis for an immigration reform organization. The job ends in a few months and doesn't have health insurance.
Within six months, the new law will require new insurance policies to permit adult children to stay on their parents' policies until they are 26.
The years McNamara has spent uninsured have been costly. Last year she spent $4,000 out-of-pocket for testing and removal of some pre-cancerous cells in her cervix.
"I'm still paying that off," she said.
Randy Lassiter, 80, also of Norfolk, is worried that his insurance plan may be subject to change of the negative sort. He describes his Medicare Advantage plan through Optima as "the best thing since sliced bread."
"I'm very concerned it will affect people like me," he said. "I'm concerned it will diminish some of my current coverage."
He's one of 159,150 people in Virginia who have enrolled in Medicare Advantage plans. That's about 14 percent of all Medicare beneficiaries in the state, a rate lower than the national average of about 25 percent.
Michael M. Dudley, president of Optima Health, said it's too soon to know the exact impact of the law on Optima's Medicare Advantage plan. "We will have to stay on our toes as the regulations are written," he said. "We can study the law, but we don't know its implications until regulations are written."
He supports more people having access to insurance but worries the penalties for people who don't buy insurance are not high enough to keep them from for going a policy. The law calls for an annual tax penalty by 2016 of up to $695.
His concern is that people will pay the penalty instead of buying insurance while they are well. But when they're sick, they'll buy health insurance.
"Without those people in the pool," Dudley said, "the practical impact will be the premiums will go up instead of down."
Jim Dahling, president and CEO of Children's Hospital of The King's Daughters, said the law holds many positives for that hospital's patients. Insurance companies would no longer be allowed to deny coverage to children with pre-existing conditions or place annual or lifetime limits on coverage.
But for the hospital, the law also has some potential for harm. CHKD qualifies for "disproportionate share hospital payments," which go to hospitals with large percentages of Medicaid and charity patients.
The law reduces those payments, because it's expected that hospitals will have more insured patients and fewer charity cases. However, 99 percent of CHKD's patient base is already insured, so the hospital doesn't stand to gain as much as other hospitals in newly insured patients.
A challenge for hospitals that serve larger adult populations will be connecting patients who turn to emergency rooms for care with new "medical homes," said Kern, of Sentara.
It's a process that won't happen overnight.
Dr. Carl Wentzel
Dr. Carl Wentzel, emergency department medical director at Bon Secours Health Center at Harbour View, said a robust primary care network will be crucial. He said in Massachusetts, which enacted a universal type of health insurance in 2006, emergency department visits initially increased after the law went into effect because people couldn't find primary care doctors.
Community health clinics have long served as an access point for such people, and the law increases their funding by $11 billion. The centers, which accept a mix of uninsured, government-insured and private-pay, expect an upswing in patients.
EVMS' Matson said the law includes some incentives for medical students to choose primary care, which could provide relief down the road. She worries, though, that people will be frustrated if they don't see positive change right away.
"It's been such an emotional issue that the first unintended consequence that comes along will make people think the whole bill is bad," she said.
The phased-in nature of the law also could cause confusion. Cathy Revell, executive director of Chesapeake Care Inc., worries that donations to free clinics - which treat the uninsured - will dry up because people will think everyone's covered now.
The center has 750 people on a waiting list for treatment, and it will be years before new insurance options open for them.
"It's a wonderful start," Revell said. "But it's not an immediate solution."