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Live Blog: Legislative Updates and PA Experiences

In this live blog from the 12th Annual SDPA conference in Indianapolis, Justin Caudle led a discussion on recent legislative updates related to the Affordable Care Act. The forum was sponsored by Johnson & Johnson Health Care Systems. Here are some of the highlights. 

Members of the SDPA gathered to discuss legislative updates at a summer conference dinner sponsored by Johnson & Johnson Health Care Systems. Justin W. Caudle, the director of healthcare policy and advocacy, presented the update. Health Care Reform has changed health insurance in a number of ways including expanded access and increased affordability. Caudle presented the changes of Health Care of Reform and engaged group discussion with PAs in the room on how they directly experience these changes.

What has been changed?

The word “mandate” never appears in the affordable care act however the document states that individuals are required to be insured, or must pay a tax for not having health insurance. The new plan has eliminated lifetime limits, and patients will no longer be asked what their pre-existing conditions are. This is especially helpful for individuals who, as sick children, used up their lifetime limit.

The language of “exchange” has changed to “marketplace.” This is simply because “exchange” does not translate regularly to languages other than English. The term marketplace now communicates the provision of a desired plan.

Other changes include exchanges created for individuals who do not have access to care and the requirement for each plan to include 10 essential health benefits. Most patients who lost their insurance due to the reform lost their plan because it did not include all 10 of the benefits.

What are the 10 Essential Health Benefits?

Outpatient care
Emergency room Services
Preventive and wellness visits, as well as chronic disease management
Maternity and newborn care
Mental and behavioral health treatment
Rehabilitation services
Lab tests
Pediatric care
Prescription drugs

Minimum coverage requirements: at least one drug in every USP category and class, or the same number of drugs in each category and class

Must provide an exceptions process: for clinically appropriate drugs that are not covered. Must allow for both internal and independent review processes

Why is the drug I’m prescribing not covered by my patients’ insurance?

It’s true that lot of the drugs that being prescribed are not covered.  This is mainly due to “Narrow-networking”, a technique by health insurance companies to narrow costs. They’ve limited physicians on the plan, limited drugs on the marketplace.  Note that every pharmacy is required to have an exception process.  If a pharmacy says they cannot provide the drug you can request an exception to the policy and they have to answer you within 24 hours.

Am I in a State that underwent Medicaid Expansion?

States that underwent Medicaid Expansion are split 50/50.  Here is a map to see where your state stands:

I see patients that pay out of pocket.  How many in my state bought insurance from the marketplace?

This is searchable on your state government website.  Here are some samples for SDPA members that attended the dinner:

1.5 million have selected a plan and that is only 42% of the eligible population

983,000 took a plan but that is only 38% of the eligible population

31,000 took a plan but 259,000 people are eligible, about 8% of the population


Dinner attendees enjoyed Caudle’s interactive presentation and the opportunity to engage in conversation with other PAs over how they see the changes of Health Care Reform in their practices.  Thank you Johnson and Johnson, and thank you SDPA!


Image: Nicolas Raymond

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