The Doctor Is In: Affordable Care Act, Part 2

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(KPLR) - Dr. Sonny Saggar stopped by the studio to continue talking about the Affordable Care Act.

In the second segment of his three part series, he discussed money and Missouri.

What's the same in every state?
When it comes to your health care options on the Marketplace, some things are the same in every state such as basic coverage.

The U.S. government sets basic guidelines for what are called 'essential benefits'. Every health plan sold in the Marketplace has to offer them.

They include emergency care, pediatric care, maternity care, lab testing,and more.

There are upper limits on how much you have to spend before your insurance company starts paying toward your care.  No plan can charge more based on your health or whether you're a man or a woman.

Four levels of coverage
To make it easier to compare plans, every Marketplace will rank the types of plans according to the level of benefits they offer, from platinum (the most) to bronze (the least). There's also a special plan for young adults.

What decisions can Missouri make?
Aside from those basic requirements, states that set up their own Marketplaces have a lot of control over what to include in their health coverage.

Which insurance companies get to sell on their Marketplace and how many
States can choose insurance companies and can set tougher rules for coverage than the federal guidelines require.

Some states,  like California, are limiting the number of insurance companies selling on their Marketplace. They hope it will improve the quality of the plans offered. Other states are taking a different approach. For instance, Colorado will allow any insurance company to sell plans.

Treatments that are covered
States running their own Marketplaces can tell companies that they must make the essential benefits more generous than the federal guidelines.

For example, some plans may pay for weight loss surgery, but others may not. Some plans may cover fertility treatments to get pregnant under maternity care, but others may not.

One plan may only cover a few drugs for your condition, like medicine for high blood pressure, while another plan may cover many brands.

What complementary and alternative treatments count as essential benefits
For instance, some states, like California, Maryland, New Mexico, and Washington, are including acupuncture as an essential health benefit. Many other states probably won't.

How to promote the Marketplace
States are in charge of advertising for their Marketplaces and encouraging people to use them. That matters. If a state is very successful in getting lots of people to buy plans, the costs of insurance in that state could go down for everyone.

Special programs
State Marketplaces may offer extra coverage for health problems that are more common in that state. For instance, if a state has high levels of diabetes, its Marketplace might include more plans that have special programs to help people with that condition.

Coverage for more people with low incomes
One way health reform was supposed to help more people get medical care was to expand each state's Medicaid plan. Medicaid is the free or low-cost health program for people with very low incomes.

However, states can decide whether or not to expand Medicaid. If a state doesn't expand Medicaid, some low-income people won't be able to afford coverage. To find out whether you qualify for Medicaid, check out the insurance finder on

Things to know about Missouri's Marketplace
Plans will vary state-to-state. If you're trying to help an out-of-state relative buy a plan, remember that their options will be different from yours.

We don't know all the details yet. What exactly will Missouri offer? Presently, nothing. Missouri has so far decided not to participate in any way in the Affordable Care Act.

The Federally-facilitated Marketplace (FFM) will be offering health coverage in Missouri in 2014. The FFM will make assessments of Medicaid/CHIP eligibility and then transfer the applicant's account to the state agency for a final eligibility determination. Missouri is not expanding Medicaid coverage to low-income adults effective January 1, 2014.

Physician's point of view
The healthier our citizens are, the more productive they are. It is as simple as that. You can't contribute much to society if you are crippled with a foot broken years ago and never repaired properly.

You can't contribute much if you are burdened by depression or an untreated psychosis or lupus or rheumatoid arthritis. We benefit from the productivity of healthy people.

Furthermore, we benefit from their health itself.

If poor people don't get checked for tuberculosis, the rest of us are at risk. If poor people don't get treated for addiction, we all suffer from petty theft to secure them a supply of drugs.

If mental illness isn't diagnosed and treated early, that burden is for all of us to bear. We pay a lot more to care for the mentally ill in prison than early treatment would cost. And it's cruel as well as expensive.

Medicaid expansion will benefit those of us who don't need it, who have health insurance, as well as benefitting those who cannot afford insurance.

But most important as a matter of law, caring for the poorest among us, ensuring that they receive the benefits of good healthcare, is a measure of the quality of our society. Do we harden our hearts and turn our backs? Or do we provide quality care to everyone who needs it?

The important thing to note is that the Affordable Care Act is not as much health care reform as it is insurance reform.

St. Louis Urgent Cares presently has 4 locations in St. Louis, and all 4 are active participants in Direct Medical Care: Downtown Urgent Care, Eureka Urgent Care and Creve Coeur Urgent Care, and North City Urgent Care. We are planning even more facilities in the near future.

Connect with Dr. Saggar, the Medical Director at St. Louis Urgent Cares at:
• Twitter: @DoctorIsInSTL
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