The new healthcare rules finally revealed

At literally the eleventh hour — 11:45pm EST — on Tuesday night, just before the start of the Thanksgiving holiday break, the Obama administration released its new health care guidelines under Obamacare.

Amidst the claims of protecting people from discrimination based on pre-existing conditions or health status (which some argue might have more easily been achieved by a simple regulation rather than a federal take-over of the country’s healthcare system), a closer look shows the new guidelines do exactly that. They also require everyone to pay for plans that include countless mandated “essential benefits,” whether or not they need or want them or to pay for them. Hold onto your hats!

Federal government releases long awaited health reform rules

The first batch of new rules have long-expected provisions forbidding insurers to discriminate against patients who already have diseases such as cancer, asthma or heart disease…. HHS stuck with a proposal that allows insurers to charge the oldest patients three times as much as they charge a 21-year-old. And the rates can go up a little bit with every birthday. But smokers can be charged premiums that are five times higher under the new rules….

The health insurance exchanges are meant to be the main place that adults under 65 can buy health insurance if they don’t get covered through an employer… The Congressional Budget Office predicts that 23 million people who don’t have health insurance now will get it on one of the exchanges… The rules on so-called essential health benefits — specific services that insurers have to offer and conditions they must cover — include 10 areas: Ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care….

“[Preventive wellness] programs must be reasonably designed to promote health or prevent disease,” HHS says. “Programs must have a reasonable chance of improving health or preventing disease and not be overly burdensome for individuals.” The plans can reward patients who lower their cholesterol, for instance, by cutting premiums.

Finally, consumers may now begin to understand what has concerned medical professionals who advocate for evidence-based healthcare for years. Take, for example, the new Billing Codes 4830-01-P; 4510-29-P; 4120-01-P mentioned at the end of the article. They fall under the Departments of Treasury, Labor and Health and Human Services (HHS): “Incentives for Nondiscriminatory Wellness Programs in Group Health Plans.”

While it says the Affordable Care Act and Health Insurance Portability and Accountability Act:

generally prohibit group health plans and group health insurance issuers from discriminating against individual participants and beneficiaries in eligibility, benefits or premiums based on a health factor, an exception to the general rule allows premium discounts or rebates or modifications to otherwise applicable cost sharing (including copayments, deductibles or coinsurance) in return for adherence to certain programs of health promotion and disease prevention.

In other words, it allows anyone noncompliant with preventive wellness programs to be penalized.

Under the new guidelines, group plans must promote preventive wellness. The new rules put “no limit on the financial incentives for participatory wellness programs,” those offered to all participants. But most favored are “health-contingent wellness programs” — those that “require an individual to individual to attain or maintain a certain health outcome in order to obtain a reward.” 

Examples of health-contingent wellness programs in the new regulations are those that impose a premium surcharge based on tobacco use or that use biometric screening tests or health risks assessments to identify people with risk factors (BMI, glucose level, blood pressure or cholesterol) and that reward those who have numbers they say are in “a normal range.”  To date, the most popular incentivized program, it states, has been health risk assessments.

The wellness programs also must require participants who are identified as being outside the normal range or “at risk” to take additional steps, such as meet with a health coach, complete a health or fitness course, adhere to a diet program or other health improvement action plan, or comply with a care plan issued by an employee or agent of the plan or issuer.

And how large are these permissible penalties?

[F]or plan years beginning on or after January 1, 2014, increases the maximum reward to 30 percent and authorizes the Departments to increase the maximum reward to as much as 50 percent if the Departments determine that such an increase is appropriate.

Currently, it states, incentives among existing plans average between “$15241 and $557,42 or between three and 11 percent of the $5,049 average cost of individual coverage in 2010.”

While, according to the new rules, the plans “must have a reasonable chance of improving health or preventing disease, not be overly burdensome, not be a subterfuge for discriminating based on a health factor, and not be highly suspect in method,” there is no recognition of the fact that these popularized “risk factors” are primarily indications of aging, along with genetics and socioeconomic status. Hence, they are discriminatory measures in themselves. Nor is there any evidence in the sound medical literature that any of the approved “preventive wellness” plans have been effective in preventing chronic diseases of aging or reducing mortality.

What does the new ruling present as evidence of the effectiveness of the new mandatory preventive wellness interventions?

Currently, insufficient broad-based evidence makes it difficult to definitively assess the impact of workplace wellness on health outcomes and cost…. [More than half of all plan sponsors surveyed report] they do not know their programs’ return on investment. The peer-reviewed literature, while predominantly positive, covers only a small proportion of the universe of programs, limiting the generalizability of the reported findings. Evaluating such complex interventions is difficult and poses substantial methodological challenges that can invalidate findings.

In other words, looking past the weeny words, there is no sound evidence.

Finally, the ruling closes with a “Federalist Statement”:

Executive Order 13132 outlines fundamental principles of federalism, and requires the adherence to specific criteria by federal agencies in the process of their formulation and implementation of policies that have “substantial direct effects” on the States, the relationship between the national government and States, or on the distribution of power and responsibilities among the various levels of government….

HIPAA provides that the States may enforce the provisions of HIPAA as they pertain to issuers, but that the Secretary of HHS must enforce any provisions that a State choose not to or fails to substantially enforce. HHS has developed procedures to implement its enforcement responsibilities, and to afford the States the maximum opportunity to enforce HIPAA’s requirements in the first instance.

To enforce participant compliance, the new ruling also noted “the regulations could be interpreted to require a revision to existing collection of information.”

The ruling is signed first by Steven Miller, Deputy Commission for Services and Enforcement of the IRS; then Phyllis Borzi with the Department of Labor; Marilyn Tavenner with the Centers for Medicare and Medicaid Services; and Kathleen Sebelius,  Secretary of the HHS.

For those who remember history, this may be sounding all too familiar.

Your body belongs to the nation! Your body belongs to the Führer! You have the duty to be healthy! Food is not a private matter! (National Socialist party, 1939)