The recent controversy involving \u201cfree\u201d contraception advocate Sandra Fluke, talk radio host Rush Limbaugh and the role of \u201cObamacare\u201d is instructive\u2014but probably not for the reasons you think. If you look past the political posturing of the people and groups involved, the controversy offers some useful insights into how health care reform works and how the kind of coverage you choose affects the cost that you pay.<\/p>\n
There are bound to be more controversies involving the implementation of the Patient Protection and Affordable Care Act. And, since this is an election year, these controversies are bound to be used to advance various political agendas. This column isn\u2019t interested in partisan politics\u2014but it is<\/em> interested in how public policy and laws affect the choices available to consumer of health insurance and medical services.\u00a0 That is, the choices available to you.<\/p>\n You might be surprised to know that the word \u201ccontraception\u201d doesn\u2019t appear anywhere in the body of the Affordable Care Act. What does appear, many times, is the phrase \u201cpreventive services.\u201d The Act states repeatedly that \u201cpreventive services\u201d include:<\/p>\n 1)\u00a0\u00a0 \u00a0 diagnostic tests for chronic conditions such as diabetes (which is, essentially how Medicare defines the phrase),<\/p>\n 2)\u00a0\u00a0 \u00a0 regular check-ups, fairly standard screening tests like mammograms and well-baby visits for small children, and<\/p>\n 3)\u00a0\u00a0 \u00a0 any other services or items as defined by the Secretary of Health and Human Services.<\/p>\n The Act also makes repeated use of the term \u201cno cost-sharing\u201d\u2014mostly in the negative\u00a0 (as in, \u201cthere shall be no cost-sharing for _____\u201d). In this context, \u201ccost-sharing\u201d means co-payments, co-insurance fees, deductibles or other out-of-pocket payments borne by the patient.<\/p>\n Combining these concepts, the Act states more than once that there \u201cshall be no cost-sharing\u201d for \u201cpreventive items and services.\u201d And it creates several task forces that are involved in defining terms like \u201cpreventive items and services\u201d in greater detail. These task forces suggest administrative rules, ultimately issued by the HHS Secretary, which define how the Act is implemented.<\/p>\n This puts a lot of power in the hands of the task forces and the HHS Secretary. More to the point, for most consumers: The HHS Secretary determines what\u2019s covered\u2014not only for government-run insurance but also for any private health insurance available in the U.S.<\/p>\n The recent dust-up involving Ms. Fluke and Mr. Limbaugh was preceded almost a year ago by HHS Secretary Kathleen Sebelius\u2019 promulgation of an \u201cinterim final rule\u201d that all forms of contraception would be considered \u201cpreventive services\u201d for the purposes of the Affordable Care Act. That interim final rule was made finally final in January of this year (though at least one stakeholder<\/a> complained that the process was completed in a panic: \u201cThere was a notification this morning and the rule came out around noon\u201d).<\/p>\n Since the Act states that preventive services shall have no cost-sharing, Sec. Sebelius\u2019 rule meant that all health insurance policies sold in the U.S. after the middle of next year must cover procedures like vasectomies or tubal ligations and items like hormone pills\u2014without requiring any deductible or co-pay.<\/p>\n