Whatever form healthcare reform eventually takes, several changes are clear now that President Barack Obama has signed the Patient Protection and Affordable Care Act into law. One is that 33 million more people will have coverage. “Which for us, as a profession, that means we’ll be getting more business,” said Barbara L. Kornblau, OTR/L, JD, dean of the University of Flint (Mich.) School of Health Professions and Studies, during an educational session at the American Occupational Therapy Association 90th Annual Conference in Orlando, Fla.

Kornblau worked as a lobbyist in Washington, D.C., during the debates leading up to the final bill. Kornblau’s interest in reform was to secure access to healthcare for people with intellectual and physical disabilities. “People with disabilities aren’t getting basic care ... forget the fancy stuff,” she said. Physical limitations can keep people from having mammograms or colonoscopies, for example, she said. Physicians’ offices do not have the proper equipment.

Focus for OTs
“There are going to be roles for OTs,” Kornblau said, “to help people get some of the access...to remind people it’s in the bill.”

The new law requires the federal government to establish regulatory standards setting the minimum technical criteria for medical diagnostic equipment to be considered accessible for people with disabilities within two years. “The Access Board is going to come up with standards, and those of you who do accessibility work may want to get involved,” Kornblau said. “They’re going to propose standards, ask for comments, and then come out with final standards, so if you have ideas on what those standards should be, have some input into that.”

At a minimum, medical diagnostic equipment covered by the new standards are to include examination tables, examination chairs, weight scales, mammography equipment, X-ray machines and other radiological equipment used for diagnostic purposes.

The law also requires the development of recommendations for quality measures to improve healthcare for individuals with disabilities. As the regulations under the law are hammered out, OTs will have to fight for their patients and their piece of the pie, Kornblau said. “What sells in Washington is stories,” she said. “We have a lot of access to those stories in our practices.”

Kornblau succeeded in having the healthcare reform bill require the collection of data on healthcare access for the disabled. “Through my work, I was able to get that into the healthcare reform bill,” she said. “Once you have the data, you have the ammunition to say, ‘If you don’t take care of people with disabilities, you lose your Medicaid.’”

The law requires the federal government to collect health survey data from people with disabilities to enable better understanding of their health compared to other minority groups. “People with disabilities are an afterthought when it comes to disparities,” Kornblau said.

The law also requires the government to collect survey data from healthcare providers. “So they can learn [where] people with disabilities get their care, the number of providers with accessible equipment and the number trained to provide healthcare for people with disabilities,” Kornblau said.

Insurance Reform
Lifetime caps on benefits have been prohibited, immediately ending the insurance industry practice of imposing lifetime caps such as $1 million, Kornblau said. As of 2014, both lifetime and annual caps on benefits are prohibited.

Also as of 2014, insurers no longer will be able to discriminate against people with disabilities or other pre-existing conditions. They no longer will be allowed to deny coverage, charge higher premiums, exclude benefits relating to pre-existing conditions, or rescind coverage after someone is injured or acquires a new condition. “You can be in a wheelchair and live life to its fullest...but when you’re sick, you can’t,” Kornblau said.

Most of these provisions go into effect for children in September.

Between now and 2014, many people with pre-existing conditions are eligible to purchase coverage through high risk pools. They must have been without health coverage for at least six months before becoming eligible for the pools, however. And the pricing could be prohibitive to some. The law allows insurers to charge older people four times as much as younger people, and deductibles can be as high as $5,950 for an individual and $11,900 for a family.

Affecting OTs directly, health insurance plans offered in the exchanges and individual and small group plans (but not grandfathered individual and employer-sponsored plans) must cover rehabilitative and habilitative services and devices, such as maintaining muscle bulk and minimizing spasticity. This is a substantial improvement, Kornblau said.

The Department of Health and Human Services is expected to further define essential benefits. The law requires HHS to take into account the healthcare needs of people with disabilities and other diverse groups. This is another area where OTs can have their voices heard, Kornblau points out, such as advocating that essential benefits include all durable medical equipment, prosthetics, orthotics and supplies.

“Go to meetings, write letters, meet with people, and organize your friends and get stories. They really make a difference,” she said. “I think that’s a really important role for us.” She suggested writing stories for OT-related publications.

Also directly affecting OTs, the Community Living Assistance and Supports provisions establish a voluntary insurance program into which people can pay, by means of a voluntary payroll deduction plan, for at least five years, then receive benefits of not less than an average of $50 a day to pay for services and supports that help them with activities of daily living.

Shifting Practice Settings
OTs may see a change in their work settings under healthcare reform. Provisions expand home- and community-based services to allow people with disabilities to live at home and participate in their communities, rather than requiring patients to live in facilities in order to receive services. Reform also provides $11 billion to support more than 1,200 community health centers.

The new Community First Choice Option allows state Medicaid plans to choose home- and community-based services for Medicaid-eligible individuals with disabilities with incomes up to 150% of the Federal Poverty Level, who would otherwise require institutional care. To encourage states to choose this option, states that opt in will receive an additional 6% added to the federal government’s share of Medicaid costs for five years. This becomes effective Oct. 1, 2011.

Reform makes it easier for state Medicaid programs to offer home- and community-based services by allowing states to amend their state plans, rather than having to apply for a Medicaid waiver.

Reform also extends the Money Follows the Person demonstration grants until September 2016. These grants provide funding to state Medicaid programs for moving Medicaid recipients who have resided in inpatient facilities into community-based settings.

Medicare/Medicaid
Healthcare reform substantially increases the number of people who are eligible for Medicaid, giving many more people with disabilities the right to healthcare coverage, according to Kornblau. As of 2014, Medicaid will cover non-elderly, childless adults for the first time and adults with incomes up to 133% of the federal poverty level. It also expands Medicaid to cover children in families with incomes up to 133% of the federal poverty level. It also extends early, periodic screening, diagnosis and treatment to all children on Medicaid, including those in managed care. These services address developmental disabilities and delays.

In addition, states are required to maintain their current services under Medicaid and have incentives to cover preventive services and immunizations without cost-sharing to adults under Medicaid.

Unfortunately, people found eligible to receive disability benefits under Social Security and other Title II programs still must wait two years before they can receive Medicare benefits, Kornblau says. Under healthcare reform, they may be able to secure coverage in the high risk pool or through the health insurance exchanges once they go into effect or they may qualify for Medicaid under its extended eligibility standards.
The new law also phases out the “doughnut hole” in prescription drug coverage, which had excluded some anti-seizure and anti-spasm drugs, by 2020, Kornblau said.

“We need to make sure people get healthcare,” Kornblau said. “Not just that the law says people get healthcare, but that they get healthcare.”

Natasha Emmons is national news editor for Today in OT.