What do the new rules about preventive services in the health care reform legislation mean for you?

First Lady Michelle Obama sits with Maggie Roberts at the event announcing the new preventive care regulations. Ms. Roberts' son was diagnosed with cancer at a well-baby visit; twelve years later, he is in remission. See more staying healthy pictures.
Associated Press/Manuel Balce Ceneta

"An ounce of prevention is worth a pound of cure," according to Benjamin Franklin, and you don't need to be a kite- flying genius to understand the truth of that statement. When you get the flu, it's easy to lament all the things you could have done to avoid turning into a sniffling, coughing mess -- a flu shot, more frequent hand-washing, avoiding the seat on the bus next to the man hacking up a lung -- but too often, we ignore the precautions and pay the price.

In the United States, we've been paying a high price for avoiding Ben Franklin's advice. Chronic diseases such as heart disease and diabetes account for 75 percent of the country's health care costs. These diseases also cause 7 in 10 American deaths. Such a steep financial and emotional charge is particularly heartbreaking when you consider that many chronic diseases are preventable.

Too often, we use our health insurance only when we get sick. A man may see a doctor when he has a heart attack, incurring sky-high medical bills, but had that same man made an appointment years earlier, he may have learned about exercising, changing his diet and quitting smoking -- factors that could have prevented his heart attack in the first place. But preventive care has not been high on Americans' list of priorities; in fact, the White House estimates that we use preventive services at half the recommended rate. When you break down that statistic, it includes everything from the 12 percent of children who have not had a doctor's visit in the past year to the 33 percent of women aged 40 or older who haven't had a mammogram in the past two years [source: U.S. Department of Health and Human Services].

Why are we so reluctant to take care of ourselves? For one thing, it can be difficult to make yourself go to the doctor when everything's fine, and for another, doctor's visits are expensive. Regular appointments would be out of the question for someone without insurance, and even those with insurance may have needed the 20 dollar co-pay for that week's groceries.

The Affordable Care Act, the health care reform legislation passed in March 2010, aims to address that second obstacle. Though Americans will still have to take responsibility for making doctor's appointments and heeding medical advice, the financial burden will be removed for many people. Read on to find out how you can receive obesity counseling, Pap smears and well-baby visits at no out-of-pocket cost.

 

What Preventive Services Does the Affordable Care Act Cover?

Preventive care saves lives and saves money. However, we tend to postpone health matters that don't have some degree of urgency, or we may not want to pay to go to the doctor when we're well. According to the White House, even a small co-pay reduces the chances of people seeing their doctors. For that reason, our health care system focuses more on treating the sick, as opposed to keeping us well.

As part of the Affordable Care Act, new rules will hopefully keep more Americans from becoming ill in the first place. For new health plans that begin on or after Sept. 23, 2010, the policy must cover certain preventive care services without any sort of customer cost-sharing -- that means no co-pay, no coinsurance, no deductible.

The preventive services covered under these new regulations fall into four main groups:

  • Evidence-based preventive services. The U.S. Preventive Services Task Force, an independent panel of health care experts that was first convened in 1984, evaluates the efficacy of preventive health treatments and diagnostic tools. Any service that they've assigned the letter grade A or B to will be covered. Grade A or B recommendations include mammography, screenings for a wide variety of conditions (including cervical cancer, colorectal cancer, depression, diabetes, HIV and osteoporosis) and a wide array of counseling services, including counseling about diet and obesity, tobacco use and alcohol use. (Some of the recommendations are dependent on the age of the patient.)
  • Routine vaccinations. Vaccines covered by the new regulations will be approved by Advisory Committee on Immunization Practices. The list includes standard childhood immunizations, flu shots, the HPV vaccine and tetanus shots.
  • Prevention for children. Insurance companies will be required to cover the service recommendations outlined by the Health Resources and Services Administration, which include regular well -baby and well-child checkups. Children will also receive services including body mass index (BMI) measurements, vision screening, hearing screening, autism screening, behavioral assessments and oral health counseling.
  • Prevention for women. These guidelines, which are being developed by doctors, nurses and scientists working with the U.S. Preventive Services Task Force, will be released by Aug. 1, 2011. Of particular interest to women's interest groups is whether birth control will be covered by the guidelines.

For a full list of the preventive services covered by the new regulations, please visit HealthCare.gov. The list will be regularly updated as medical advances occur.

If you're confused about how this will apply to your particular health care plan, check with your provider. Some insurance plans already offer excellent preventive services coverage, and some insurance plans won't have to change their regulations because they have grandfathered status. That means they will be able to continue to charge co-pays or deductibles for preventive care, though they may opt to follow the new regulations. Medicare beneficiaries will see the changes take place on Jan. 1, 2011. For some people, though, the changes will have an immediate effect: If you enroll in a plan that begins on or after Sept. 23, 2010, though, then you should be able to get a mammogram or have your child immunized at no out-of-pocket cost.

What are the Costs and Benefits of the Preventive Care Rules?

Hearing screenings are one of the many new services that are to be provided with no out-of-pocket cost to the patient.
Hearing screenings are one of the many new services that are to be provided with no out-of-pocket cost to the patient.
Jupiterimages/Thinkstock

The White House estimates that premiums may rise by 1.5 percent to account for the new preventive care rules, but out-of-pocket costs will be more manageable. For example, a 58-year-old woman receiving a mammogram, a colon cancer screening, a Pap test, a diabetes test, a cholesterol test and a flu shot might spend $300 in co- pays for these tests; if she's covered by the new rules, however, she won't pay a dime.

It's hoped that long-term costs will decrease when up-front investments are made in Americans' care. For example, obesity and related illnesses are one of the biggest drivers of health care costs. Counseling on exercise and a healthy diet, in conjunction with regular check-ins and screenings, could go a long way in averting some of those long-term costs. And of course, regular preventive care can save lives because patients can address controllable risk factors and gain the advantage of early detection and treatment. According to a study cited by the White House, administering just five preventive services -- colorectal and breast cancer screenings, flu vaccines, and counseling about smoking and regular aspirin use -- could prevent 100,000 deaths each year. There are benefits to employers as well -- since sick days represent a tremendous loss in productivity, healthier workers lead to a healthier bottom line.

By the end of the next year, the White House estimates that 31 million people in new employer plans and 10 million people in new individual plans will have access to these preventive care services without having to worry about co-pays or out-of -pocket costs. The number of people covered by new employer plans is expected to jump to 78 million by 2013 [source: White House].

The ultimate success of this program will depend on those people who have this type of coverage. While the Affordable Care Act has removed one of the major barriers to preventive care -- cost -- it's up to the individual to go to the doctor and heed the recommendations the doctor provides.

For more information about the Affordable Care Act, visit the government's Web site, HealthCare.gov. If you'd like more HowStuffWorks articles about the legislation and how it affects you, please see the links on the next page.

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Sources

  • Alonso-Zaldivar, Ricardo. "Some preventive care to have no out-of-pocket cost." Associated Press. July 14, 2010. (July 14, 2010) http://www.google.com/hostednews/ap/article/ALeqM5gXYo aWJIWcnfxX8EQ9Q5PleI9XogD9GUV2TG1
  • Clark, Anna. "The fight for free birth control continues." Salon. July 14, 2010. (July 14, 2010) http://www.salon.com/life/broadsheet/2010/07/14/birth_ control_coverage
  • HealthCare.gov Web site. U.S. Department of Health and Human Services. (July 14, 2010) http://www.healthcare.gov/
  • Pear, Robert. "Health Plans Must Provide Some Tests at No Cost." New York Times. July 14, 2010. (July 15, 2010) http://www.nytimes.com/2010/07/15/health/policy/15heal th.html?_r=1