Justia Legal Guides: Health Care Law Center

This month marks the 13th anniversary of the Patient Protection and Affordable Care Act, which President Barack Obama signed on March 23, 2010. Often known as the Affordable Care Act or simply as “Obamacare,” this federal law marks perhaps the greatest achievement of the Obama administration. The ACA vastly expanded access to health insurance, allowing millions of Americans to get coverage for the first time. However, its reforms sparked a fierce backlash, partly due to disagreements about how much the government should control health care. Much of the controversy swirled around a provision known as the individual mandate, which requires most people to get health insurance. Republicans in the U.S. Congress have repeatedly sought to repeal the ACA without success. Former President Donald Trump also promised that he would undo his predecessor’s efforts, but this pledge went unfulfilled.

The law also has faced constitutional challenges, some of which have reached the U.S. Supreme Court. Despite being dominated by a conservative majority, the Court has upheld the ACA time after time. For example, in National Federation of Independent Business v. Sebelius, the Court decided 5-4 that the individual mandate was constitutional under the taxing power of Congress. Most recently, in California v. Texas, the Court relied on procedural grounds in ruling 7-2 that various Republican-controlled states could not challenge the individual mandate.

The reforms brought by the Affordable Care Act are just one of the topics addressed by the Health Care Law Center at Justia. Consumers can visit this section of the Justia Legal Guides to learn about issues involving health insurance, as well as government benefits programs Medicare and Medicaid. The Health Care Law Center also addresses topics specific to the LGBTQ+ community and to veterans of the U.S. armed forces.

Health Insurance and Covering Medical Costs

Health insurance form

The Justia overview of the Affordable Care Act explains how its provisions affect both individuals and employers. As it points out, a later law called the Tax Cuts and Jobs Act has wiped out the tax penalty attached to the individual mandate, although this provision of the ACA remains on the books. Some people still may face penalties under state law for failing to get health insurance, which has been made available through exchanges operated by state governments and non-profits. Meanwhile, employers with 50 or more employees will face stiff fines if they fail to provide health insurance to their employees.

The Affordable Care Act built on an earlier federal law called the Health Insurance Portability and Accountability Act. HIPAA is often known for protecting the confidentiality of patients’ medical records and giving them rights to access these records. In addition, it improved access to coverage for people with “pre-existing conditions,” which are medical conditions for which they received care before enrolling in their new plan. This law limited the lookback period for pre-existing conditions to six months, and it further required insurers to provide coverage for conditions within the lookback period no later than 12 months after a consumer enrolled in a plan. The ACA went even further by removing the lookback period. Currently, insurers cannot deny coverage or charge higher fees to people with pre-existing conditions.

While health insurance has improved in recent years, it may not cover all of the medical costs that a consumer incurs. To account for costs not covered by insurance, a consumer might consider opening a medical expense account. Two types of medical expense accounts, flexible spending arrangements and health reimbursement arrangements, are usually tied to employment. A health savings account is not. A consumer who wants to create an HSA must combine it with a high-deductible health insurance plan, which provides for lower premiums and higher deductibles and out-of-pocket maximums.

Medicare and Medicaid

Medicare and Medicaid stamps

Two government programs that can help cover some types of healthcare costs are Medicare and Medicaid. First, Medicare is available to people who are 65 or older and eligible for Social Security benefits, as well as certain other groups. Part A of Medicare covers hospital or hospice care and some home health care, while Part B covers medically necessary services, and Part D covers prescription medications. The payments that consumers must make vary for each of the three parts.

Meanwhile, Medicaid is generally meant to assist financially disadvantaged Americans. This program may provide broader coverage than Medicare, but coverage depends on the state because each state manages the federal funds provided for the program independently. Eligibility for Medicaid hinges in part on meeting financial requirements, but applicants also must meet other criteria. An applicant who is financially eligible usually can receive Medicaid if they have a disability or if they are pregnant or over 65, or if they have breast or cervical cancer, but some states have expanded Medicaid coverage to other groups, such as people who are “medically needy” because their healthcare costs are very high.

When a Medicaid recipient passes away, the state may be entitled to recover funds from their estate as reimbursement for benefits. Laws vary as to whether the estate includes all property owned by the recipient at death or only the property in their probate estate. Sometimes a state might even pursue Medicaid reimbursement through a lien on the recipient’s real estate. This could allow the state to get reimbursed even before the recipient dies if they sell the property.

Distinctive Issues for Certain Consumers

Hands holding healthcare icons

Unfortunately, Americans in the LGBTQ+ community may encounter discrimination by doctors, which can affect their access to treatment and overall health. A provision of the Affordable Care Act forbids discrimination by hospitals and healthcare programs that receive federal funds, and some states have enacted anti-discrimination laws. In the area of insurance, LGBTQ healthcare rights have expanded under the ACA and the Obergefell v. Hodges decision, in which the U.S. Supreme Court recognized a constitutional right to marriage (and its associated benefits) for same-sex couples. The ACA forbids discrimination in health insurance based on sexual orientation and gender identity, and it eliminates a loophole that some insurers used to deny coverage to transgender people. After Obergefell, health insurance benefits through employment must be equally available to people in same-sex marriages as to people in opposite-sex marriages.

Other issues in health care that may pose distinctive concerns for LGBTQ+ individuals include hospital visitation rights, advance directives, and laws limiting blood donation by gay and bisexual men. Transgender individuals may face particularly severe obstacles and may have legal rights to assert if they are mistreated due to their gender identity.

People who have served in the U.S. military may qualify for healthcare benefits through the U.S. Department of Veterans’ Affairs if they served on active duty and left the armed forces through a means other than a dishonorable discharge. Generally, they must have served for at least 24 consecutive months or have been discharged due to a service-related disability. Some veterans may be enrolled for VA healthcare benefits automatically, while others will need to apply. The VA assigns each veteran to one of eight priority groups, which can affect how much of their medical costs they will need to pay.

Final Thoughts

Medical costs can mount rapidly, but access to health care is critical. Americans should understand their rights under health insurance laws such as the ACA and HIPAA. They also should know about the eligibility requirements for Medicare and Medicaid benefits. When a consumer faces a legal obstacle, they may want to consult a health care lawyer to find out more about the scope of their rights and how to assert them. In the meantime, the Health Care Law Center at Justia provides a useful introduction to the topic with some general principles to keep in mind. It aims to make the law transparent and accessible to all.

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