In my own little corner of American medical care, so far I haven’t felt much of a ripple from the Affordable Care Act (or, if you prefer, “Obamacare”). The changes in insurance regulation that have already gone into effect don’t seem to have had much impact my patient population. I had some misgivings about the bill (I was very unhappy about the lack of a public option), and I think its sheer mass and opacity made it hard for even attentive Americans to know exactly what we’re getting. However, I remain hopeful that it will improve medical coverage for people who would otherwise lack it.
Unfortunately, what little ripple I have felt is discouraging. For people who have opted for coverage using a Health Savings Account (HSA), the ACA has made life perceptibly worse, and for no good reason that I can think of.
HSAs allow people to save a portion of their income for health purposes, and to avoid paying taxes on that portion. Typically they are combined with enrollment in a high-deductible insurance plan. I have to admit I don’t fully understand all the regulations that govern HSAs, but for patients who can afford a certain amount of out-of-pocket cost, they strike me as a good idea. Certainly, patients who use them have a better sense of what their health care costs may be as they are paying them directly up to a point, and I think there’s some merit in that. Once patients reach their annual maximum, the high-deductible plan covers remaining costs. It doesn’t seem a bad option for otherwise healthy young people wanting catastrophic coverage.
So, how has the ACA made HSAs noticeably worse? Used to be you could use them for over-the-counter medications, and now you can’t. (The 2004 regulations are available as a PDF, with the relevant information about halfway through — “Now includes over-the-counter drugs.”) Saints have mercy on my soul, I have found a policy for which Obama took a perfectly good Bush-era regulation and made it crappier. (Doubtless motivated commenters may feel moved to point out others.)
I can think of no good reason that over-the-counter medications cannot be paid for out of an HSA. The money in the account belongs to the person who saved it. Over-the-counter medications have no practical non-medical use, outside of creatively rejiggering Sudafed for recreational purposes (and we already have laws for that). Over-the-counter medications are safe enough to be available without a prescription (and we already have an agency to ensure that). Why should patients need a prescription from me to spend their own money from an HSA for an over-the-counter medication?
If this is some kind of asinine attempt at lowering healthcare costs, allow me to aver that it is a failure for a host of reasons. First, people are going to buy the medications they want, the only difference being whether payment is drawn from untaxed income or taxed. The government won’t reap any benefit from having that portion of the HSA unused. Perhaps this is a nannyish attempt to keep patients from frittering away their saved pennies on medications they don’t really need, but I happen to think we don’t really require federal oversight on whether people should be allowed to spend their own money on things they think they need, healthcare or otherwise. HSAs are for healthcare expenses, and medications (over-the-counter or otherwise) are healthcare expenses. What further scrutiny or explanation is necessary?
What’s more, it’s not as though patients are going to be daunted by the need for a prescription. No, if my experience is any indication, they’re just going to ask their doctors to write out prescriptions for medications that otherwise wouldn’t require them. It’s happened to me several times already, often coming as a phone or e-mail request. If I were a real schmuck about it, I could refuse to provide a prescription absent an office visit, thus adding the price of the visit to the otherwise low cost of the medication. Since I try to avoid being a schmuck whenever I can help it, I simply provide the prescription. Between my front desk staffer who fields the call, me writing the prescription and the pharmacist processing the needless order, you get the steady accretion of uncompensated, tedious busywork that is always the hallmark of truly outstanding policy.
In all seriousness, I would truly love to have someone give me a plausible explanation for this change in policy. Any sane reason the government should keep people from using money they’ve saved for healthcare costs on otherwise easily-accessible medications already determined not to require a prescription is welcome. The ACA may have touched my practice very lightly, but I can’t say I like what I see so far.