National Nurses United

What they're not telling us about the exchanges with global budgeting, b) rejecting a proposal to authorize the federal government to negotiate bulk purchasing (a concession to the drug companies), and c) failing to regulate price gouging by hospitals, drug companies, insurers, and other healthcare corporations. Those restrictions are hardly surprising given the administration's choice to write the law in collaboration with pharmaceutical, insurance, hospital, and Chamber of Commerce lobbyists, and top Wall Street investment firms and hedge fund executives. That left only two ways to produce substantial reductions in health expenditures—shifting costs to those who use health services while discouraging them from getting care, and promotion of cheaper care delivery schemes often designed at the expense of quality care. Slashing utilization of medical care has long been the scorchedearth solution promoted by some supposed experts for cutting costs. It stems from some highly publicized abuses of a few practitioners who prescribe diagnostic procedures or medical treatment to profit from the reimbursements. But it also coincides with the portrait of patients as a whole class of "takers" who somehow enjoy spending hours waiting in doctors' offices or undergoing colonoscopies, a theory that has race, gender, and class overtones, blaming minorities, women, and the poor for demanding "too much" care. In concert with ACA implementation, for example, the Institute of Medicine is set to propose that Congress pay less to hospitals and doctors in areas where there is heavy use of medical services, even as a new research study in Medical Care Research and Review has poked huge holes in the premise, noting that up to 85 percent of the differences are related to health conditions, sicker patients, not overutilization. Here are a few of the gaping cracks in the ACA, including several that have received little or no attention in the media or by defenders of the law. JUNE 2013 the aca health exchanges are marketplaces set up with competing private insurance options for the uninsured, whom the law now requires to buy private insurance or pay a financial penalty. Those who buy insurance through the exchanges can qualify for a federal subsidy, depending on their income, to partially cover out-of-pocket costs. But premiums, deductibles, co-pays and other fees can run to thousands of dollars. Even in the cheapest, high-deductible plans, buyers are expected to pay 40 percent of the cost. Many younger, healthier people are likely to gamble with their health by selecting the highdeductible plan or go without coverage entirely and pay the fine. If healthier people opt out, the risk pool collapses, providing insurers a further excuse to jack up rates and put more pressure on public budgets, as has occurred in Massachusetts, the ACA model. A Health Affairs study found that 38 percent of families buying plans through the Massachusetts exchange reported a financial burden and 45 percent said costs were higher than they had expected. Medical bills still account for more than half the personal bankruptcies in the state. Further, while the law requires plans in the health exchanges to offer specific benefits, it fails to define the amount of the benefit offered or the duration for which the services are provided. In yet another major loophole, small businesses can buy coverage for employees through the exchanges, but the premium and co-pay subsidies will not cover spouses or other family dependents. The high cost of taxing health benefits for the first time, the law will tax health benefits beginning in 2018 through the misnamed "Cadillac tax," a 40 percent excise tax on comprehensive health plans. Inevitably, fewer employers will offer good health benefits, and far more people will be pushed into skeletal, high-deductible plans with far less coverage and higher out-of-pocket costs. The New York Times recently reported that 17 percent of employers this year are stepping up cost shifting—five years before the tax goes into effect. An incentive to employers to cut coverage or full-time jobs employers with 50 workers or more are required by the ACA to offer coverage to full-time employees or pay a fine. Employers are not required to provide coverage to part-timers. Nurses and other workers are increasingly in battles with employers, such as Sutter Health, who are demanding elimination of coverage for part-time employees and citing the ACA as their pretext. Denny's Restaurants, Regal Entertainment, Papa John's, and other companies are reducing workers' hours to 30 hours a week or less. W W W. N A T I O N A L N U R S E S U N I T E D . O R G N AT I O N A L N U R S E 17

• Cover