Posts Tagged ‘pre-existing conditions’

On This Mother’s Day, the Affordable Care Act Keeps Working for Our Children

Monday, May 9th, 2011

Having celebrated Mother’s Day with my mom this past weekend, I know that despite leaving home over a decade ago, she’s still always looking out for me. And she is not alone. Moms (and dads, too) across the country are making sure their young adult children are well taken care of even after they leave home by adding them on to their health insurance plans. Most young adults under 26 are eligible to remain on their parents’ plans if they don’t yet have access to employer-sponsored plans.

This provision from the Affordable Care Act (ACA) was always very popular with the public—but until recently, no one was sure just how successful it would be. Initial indicators suggest this option may turn out to be an even bigger success than many of us originally anticipated.

The United States Department of Health and Human Services (HHS) previously produced a mid-range estimate that projected 1.2 million young adults to gain new coverage under this provision in 2011. Just last week, it was reported that at least 600,000 young adults have already been added to their parents’ plan — and we’re just a third of the way through the year. This suggests that there’s a shot to reach the high estimate prepared by HHS of over 2.1 million young adults gaining new coverage in this year alone.

Another piece of good news is that young adult children in military families are also eligible to take advantage of this option. Eligible children of service members up to age 26 can purchase health care coverage under their parents’ TRICARE plans, retroactive to January 1, 2011. These children were not originally included in the ACA provision and, until this year, lost access to their parents’ plans at age 21 (or 23 for full-time college students).

If you’re interested in learning more about the ACA young adult coverage provision, check out both this blog post by HHS Secretary Sebelius as well as the state-specific resources prepared by our partners at Young Invincibles at their Getting Covered website. We’ve also blogged about the young adult provision previously.

The ACA’s success in improving young adults’ access to health insurance coverage is just one of many ways that it’s helping children. Don’t forget that the ACA also requires that insurers cover children with pre-existing conditions and increases access to preventive care by eliminating cost-sharing for preventive services.

In short, the ACA is giving moms across the nation reason to feel confident that their children have better access to coverage and care. Healthy children — now there’s something every mom wants for Mother’s Day!

—Patrick M. Tigue, Children’s Health Care Coordinator
New England Alliance for Children’s Health

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A Government Shutdown of Women’s Health?

Friday, April 8th, 2011

Since the new Congress came to Washington DC some Republicans in the House have been very concerned with women’s health care; however, not necessarily in a good way.

In the last few months, the House Leadership has tried to eliminate funding for Title X, the federal family planning program, passed an amendment that bans Planned Parenthood from receiving any federal funds to provide health care services to their communities, and introduced legislation that attempts to further restrict access to abortion services.

(For more about the legislation see Kaiser’s side-by-side comparison.)

As I write this blog, the latest news reports are saying the federal government shut down may hinge on whether Planned Parenthood is allowed to receive federal funding to provide needed health care services like family planning, sexually transmitted infection testing and counseling, HIV/AIDS testing and counseling and pap smears. None of the federal funds Planned Parenthood currently receives are allowed to be used for abortion services.

Members of Congress who support slashing funding for Planned Parenthood and important women’s health programs are the same individuals who want to dismantle and defund the Affordable Care Act. What were their first actions when they came to Washington in January? They introduced legislation to repeal the ACA — including trying to dismantle the carefully crafted abortion compromise in the law. Tying the two issues together allows opponents to spread misinformation and confuse the public about the ACA.

We took big strides forward when we passed the ACA to ensure access to health care services for families. For women, in particular the ACA:

  • – Stops insurance companies from denying coverage for pre-existing conditions – including pregnancy;
  • – Covers preventive services like mammograms and other preventive screening without out-of-pocket costs;
  • –  Lowers health care costs for women by not allowing women to be charged more than men.

Allowing any of the proposals in the House discussed here to move forward is a slippery slope that could cause real harm to women’s health. Our elected officials should be working to ensure access to women’s health care services is not undermined so women can get the health care they need, when they need it.

– Reena Singh, Field Coordinator

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Health reform makes for healthier women

Thursday, March 24th, 2011

To mark the first anniversary of the Affordable Care Act this week, Health Policy Hub will be cross posting blogs from our state partners that show how people in their states are benefiting from the law. This blog was originally posted on the Health Care for All New York blog.

Women were among the strongest supporters of health reform in the campaign that led up to President Obama’s signing of the Affordable Care Act (ACA) on March 23, 2010. One year later, women and girls across New York State are experiencing the benefits of the ACA provisions that have gone into effect so far. Raising Women’s Voices, an active member of the HCFANY steering committee, is working to inform women about benefits like these:

  • – Young women can now stay on their family health insurance policies up to age 26. This new provision, which applies to all young adults, is especially important for young women, who are in their prime reproductive health years and need affordable family planning and primary care services. It also provides peace of mind for all those moms worried about how their children will maintain health coverage after graduating from high school or college, when so many entry-level jobs no longer include health insurance. Want to know if this applies to your family’s insurance policy and, if so, how to take advantage of it? Go here.
  • – Women who are insured can now get preventive care – such as mammograms and Pap smears — without having to come up with co-pays or deductibles. Out-of-pocket costs can discourage women from seeking the preventive care they need. Many important women’s health services are covered by this new provision. Wondering which services are included? Go here to see the list. Of course, we still want to see contraception added to the list. Women can sign the Raising Women’s Voices petition asking the U.S. Department Health and Human Services to declare that Contraception is Prevention by going here.
  • – Older women on Medicare now can get annual physicals without co-pays. Also, Medicare enrollees who fall into the Prescription Drug Part D “donut hole” are eligible for 50 percent discounts on brand-name prescription drugs this year, to help hold down their out-of-pocket costs. Yes, these are real women’s health issues! According to the Kaiser Family Foundation, 58 percent of Medicare enrollees in New York State are women. To learn more about how to take advantage of these new provisions, go here.
  • – Health insurance companies can no longer require you to get a referral from your primary care doctor before you can seek obstetric or gynecological services from an ob/gyn who participates in your plan. This new provision means you can get to your ob/gyn quicker, without having to jump through the hoop of obtaining a referral. Learn more about this provision here.
  • – Women who have pre-existing medical conditions and can’t find affordable private health insurance can now get insurance through the New York’s Bridge Plan. Having a medical condition like breast cancer, diabetes or heart disease can make it nearly impossible to find affordable health insurance in the private market in New York State. A woman we know in Queens who has pre-existing medical conditions couldn’t afford the only policy she could find, because the monthly premium was going to be $1,200! Now, she has signed up for New York’s new Bridge Plan and will be getting health insurance for less than $500 a month. The list of pre-existing conditions that qualify you for enrollment in this plan include high-risk pregnancy, complications from pregnancy, uterine fibroids, endometriosis and a number of other conditions specific to women.

Raising Women’s Voices has prepared a fact sheet of the top 10 benefits women and our families are already getting from the Affordable Care Act. You can find it here.

Click here to view HCFANY’s policy brief, “Health Reform: What’s in it for women?”

Other great sources of information about how the Affordable Care Act helps women include:

— Lois Uttley, Director Merger Watch Project
Co-Founder, Raising Women’s Voices

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ACA Protections Go to Campus

Thursday, March 3rd, 2011

Earlier this month, the U.S. Department of Health and Human Services (HHS) released a new proposed rule that takes an important step toward ensuring that students who purchase a health plan through their university or college will be able to benefit from the same basic consumer insurance protections in place for all individual market plans under the Affordable Care Act (ACA). The proposed rule represents an important victory for the more than one million students who are enrolled in these plans because the plans have historically varied widely in terms of both premiums and benefits — creating incredible hardships for some students.

For example, our partners at Young Invincibles have chronicled the stories of real students who have faced serious difficulties while covered by a student health plan including:

  • – A student with a plan that covered a maximum of $500 annually for over-the-counter prescriptions—leaving her without adequate coverage for her Type 1 Diabetes.
  • – A student with a plan that did not cover the amount of chemotherapy and testing her doctor determined was necessary during treatment for a rare form of cancer called Ewing’s Sarcoma—leaving her with $80,000 in medical debt.

For more stories like these collected by Young Invincibles, click here.

Thankfully, the proposed rule would ensure that students across the country have more protections than ever before because the following ACA individual market provisions would apply to student health plans issued after January 2012:

  • – Insurance companies would no longer be allowed to impose lifetime dollar limits on benefits in student health plans.
  • – When student health plan enrollees get sick, insurance companies would no longer be allowed to drop coverage because of an unintentional application error.
  • – Insurance companies would be prohibited from denying or excluding coverage for students under age 19 because of a pre-existing condition. In 2014, this would apply to students age 19 and over as well.

By proposing to apply these protections to student health plans, HHS is essentially saying that it does not consider student health plans to be so unique that they deserve to play by entirely different rules than other individual market plans.

HHS deserves quite a bit of credit interpreting the ACA in this way because there is language in the law that emphasizes that that the statue should not be applied in a way that would prohibit a college or university from offering a student health plan. Because HHS needs to pay attention to this part of the law as well, the proposed rule attempts to limit the way in which other consumer insurance protections apply to student health plans. For instance:

  • – Insurance companies, for their student health plans, would not be required to follow the Health Insurance Portability and Accountability Act’s guaranteed availability and renewability rules. To do so would require student health plans to be made available to individuals who are no longer students.
  • – Even though the ACA largely prohibits cost-sharing for preventive services, administrative fees charged by colleges and universities to fund student health services (including preventive services) would not be considered cost-sharing and would remain permissible under the proposed rule.
  • – Insurance companies would have more flexibility than other individual market plans as they phase-out annual dollar limits on benefits for student health plans. For policy years beginning anytime from January 1, 2012 to September 23, 2012, annual limits could be no less than $100,000. Student health plans would then be required to follow the same rules as other individual market plans, including a complete elimination of annual benefit limits starting on January 1, 2014.

The bottom line is that HHS has proposed to apply as many of the individual market consumer insurance protections as is permissible under the ACA to student health plans and this will make a enormous differences in the lives of many students enrolled in these plans.

Still hungry for more analysis about the new student health plans proposed rule? Check out this post at The Commonwealth Fund Blog and this post over at the HealthAffairs Blog.

— Patrick M. Tigue, Children’s Health Care Coordinator
New England Alliance for Children’s Health

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The Insider: Repeal Watch

Tuesday, April 27th, 2010

With Enemies Like This, Who Needs Friends?

As they tried to regain their footing after the surprise Senate election of Scott Brown, reformers received an unexpected boost from for-profit insurer Wellpoint. In February, the insurance giant announced it was planning to raise rates by 39 percent in California, and similarly large increases were reported elsewhere. Coming off a $2.5 billion profit in the last quarter of 2009, this didn’t sit so well with much of anyone but insurers, and became a major rallying point in the White House, Congress and advocates’ final push for reform. Some conservative commentators went so far as to blame Wellpoint for reform’s subsequent passage.

Now Wellpoint is at it again.  Recent headlines suggesting that the company routinely targets women with breast cancer for rescission boost the case that, if anything, the tougher insurance oversight that is part of the Patient Protection and Affordable Care Act doesn’t go far enough.   Since it seems the folks at Wellpoint can’t help themselves, it’s up to advocates and regulators to stop them before they kill again (no joke).

Repeal Watch 1: Public opinion
This latest Wellpoint scandal makes it crystal clear: The repeal chorus is defending the indefensible.  And yet, with 45 percent of conservatives getting most of their information from cable news, it’s unclear that the indefensible is making it on air. The latest Kaiser tracking poll (pdf) has some moderately good news for reformers: a plurality of the country supports reform, but many are confused (or misinformed) about what reform actually does.

This lack of understanding underscores both the need and opportunity for an aggressive public education effort using all available means—everything from paid and earned (and social!) media to one to one conversations at the community level.

More bad news for repealers (and good news for us): there is strong cross-partisan public support—among Democrats, Republicans and Independents—for the early provisions of reform like small business tax credits, $250 rebate for seniors with high drug costs and coverage for children with pre-existing conditions.

But people over 65 continue to hold a more negative view of reform than younger adults do—and that’s worrisome, especially in light of their disproportionately big turn out at the mid-term polls, which we’ve talked about here before.

Even so, repeal may not be the ticket to ride that some conservative activists hoped for. A recent poll of Florida voters showed that a majority think that the state Attorney General McCollum’s decision to sue the federal government was a bad idea and that McCollum, the front runner in the Florida governor’s race, was losing ground.

Repeal Watch, Part 2:  Breaking down the repeal arguments

Voters have good reason to be skeptical of the repeal efforts, which have overwhelmingly been advanced by candidates seeking higher office or as part of a larger right-wing electoral strategy. A growing number of state legislatures hold a similarly skeptical view—so far more than 12 have rejected repeal measures.

And they are right to, since the main repeal arguments are so far-fetched.  Basically, they amount to:

  • The law is illegal because the Medicaid expansion imposes new costs on states. By the same reasoning, other provisions of Medicaid law, such as the requirement to cover certain children or people with disabilities, would also be illegal, and Medicaid would become nothing more than a blank check written to the states. And what of those new costs? A recent CBPP report shows that new state costs through 2019 add up to only 1.25 percent of projected state spending, and that’s before factoring in possible offsetting savings to states.
  • States have the ability to selectively decide which federal laws they will obey. This argument essentially parallels the case made by segregationists almost 50 years ago and has been decisively rejected by the courts.
  • The individual mandate falls outside of Congress’ authority to regulate interstate commerce because it regulates “inactivity” and/or it is an impermissible tax.

But from a legal standpoint, the “mandate” falls squarely within Congress’ authority to raise taxes. Semantics aside, the individual mandate is not really a mandate, but a financial incentive to purchase coverage.  From an economic standpoint, it is no different than the existing tax subsidy that goes to employer-sponsored coverage; lowering the cost of doing something or raising the cost of not doing it are functionally the same (more at the New England Journal of Medicine–subscription required).

In sum, both the legal and political campaigns for repeal (if indeed the two are distinguishable) rest on shaky ground—and more and more voters and political leaders are beginning to figure that out.

–Michael Miller, director of strategic policy

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The Insider: Implementation Nation

Tuesday, April 20th, 2010

Although the national media spotlight has moved on, the work of health care reform is only beginning. Today we  look at some of the recent developments in Massachusetts—which is sort of a health reform “beta site”—and what they tell us about reform in the rest of the country. We’ll also examine one of the early implementation provisions: the temporary high-risk pool.

Massachusetts: The gift that keeps on giving

Throughout the debate on national health care reform, Massachusetts has played an outsized role. The bipartisan nature and popularity of reform in the state, its success at reducing the number of uninsured, and the prominent role Massachusetts pols from both parties played in the national reform saga have all helped to make what happens in the Bay State unusually significant. This is likely to continue to be true going forward.

Because Massachusetts is farther down the implementation path, it has already encountered issues that will come up in other places. Three recent developments in Massachusetts highlight the state’s continuing relevance to the reform debate.

The first is the controversy over insurance premium rate hikes.  Earlier this spring, the Massachusetts Division of Insurance denied dozens of premium rate increases as being excessive. (See the Boston Globe article.) The ruling led to a court challenge by insurers and a brief insurance “strike” as Massachusetts insurers took their plans off the market.  (Since the court refused to grant the insurers a preliminary injunction most plans are again available). Although this preliminary ruling went against the insurers, there is no guarantee about the final outcome.

The takeaway? Insurers will play hardball to resist downward pressure on premiums. States need strong tools and political will to fight back. An effort to beef up premium oversight had to be stripped from the final national health reform bill because it did not fit within the rules of the budget reconciliation process, but a stand-alone rate regulation bill is being championed by Sen. Diane Feinstein. A hearing is scheduled for this Tuesday in the HELP committee, but odds of passage are uncertain, since it’s likely that Republicans will present a united front in opposition, making it hard to get the necessary 60 votes.  In the absence of federal authority,  advocates may want to turn their attention to strengthening state oversight.

A second issue to hit the Boston media recently also has lessons for national reform. Insurers allege that there is a group of people taking advantage of continuous open enrollment to purchase non-group insurance for a short period of time, schedule costly medical care, and then drop out. Like so much of national reform, this claim comes with a heavy dose of politics attached, since the charges are being made by a former insurance industry exec who’s running for governor.

These “short-stayer” allegations have yet to be substantiated. So far insurers have not provided data which shows what medical care alleged short-stayers are using, whether or where they were previously insured, and whether the problem is growing or actually diminishing. The Division of Insurance is studying the issue and its report is expected soon.

Meanwhile, we can and should expect insurers to fight to undermine the impact of guaranteed issue by narrowing access to insurance. This battle will be fought first at the federal level as HHS determines the initial and subsequent enrollment periods, and it’s critical that consumers push back to make sure that insurance remains as accessible as possible.

The third implementation issue in Massachusetts with implications for the states is one that has received no media attention (and was not heeded by federal lawmakers during the debate): When it comes to helping people make informed choices among competing insurance plans, standardizing actuarial values is simply not enough.

Within any given benefit tier (gold, silver, etc.), insurers can vary cost-sharing arrangements so much that comparison remains difficult. Focus groups in Massachusetts show what those done by national organizations do: What people want is better choices, not an infinite number of choices. And so after several years of experimenting with actuarial value, the Massachusetts Connector has moved to standardize benefits. Federal law does not require states to create standard benefits, but it does not prohibit it, either. Nor is there any reason that standardization has to wait for the 2014 kick-off of health insurance exchanges.  Advocates should consider pushing for greater standardization in their state markets now.

High-Risk Pool rules present states with tough decisions

One of the first provisions of national health care reform slated to be implemented (90 days after passage) is the creation of a temporary high-risk pool (HRP) for those excluded from coverage due to a pre-existing condition. As welcome as this new program is, given that most existing state high risk pools perform poorly, it may prove difficult to effectively integrate the new program with existing state law.

PPACA establishes a set of rules for both the federal HRP and any existing state pool that wants to tap into the $5 billion in federal support made available by health reform.  These rules include setting a minimum actuarial value and out-of-pocket maximum for HRP coverage. They also prohibit the imposition of pre-existing condition exclusions, require rates to be the same in the HRP as in the market generally, and set a limit on age rating of no more than 4-1. All of these are welcome changes.

However–and it’s a big however–federal law also restricts eligibility for the HRP to those who have been uninsured for at least six months. While this provision is designed to prevent people from dropping existing coverage to enroll in the federal plan and to help stretch federal dollars, it also creates some problems. Consider these four types of states:

States with no HRP and no guaranteed access to insurance in the non-group market–For these states there is no problem: Either the state will set up an HRP that meets federal standards, or the federal government will set up a pool on behalf of the residents of that state. End of story.

States with an HRP that is worse in all respects to the federal law–A state could “true up” its program to meet federal requirements, or it could do nothing, in which case the federal government would set up a parallel program.

What happens then? Everyone with a pre-existing condition (who can afford the premiums) can enroll in the federal program except those who are already enrolled in the state HRP. They either have to take the risk of going without coverage for six months, or remain locked into inferior and costlier coverage in the state pool.

States with an HRP that does not require a six-month wait–Even if a state pool is as good as or better than the federal requirements in most respects, the requirement for a six-month waiting period could create problems.

In general, states can run a program that is better than the federal program if they choose. But, if states do not impose a six-month waiting period, their program will not qualify for federal assistance.So they have the choice:   either impose a new access restriction on people with pre-existing conditions, or set up a parallel pool (or allow the federal government to). In the latter case, those who can take a chance on going without coverage for six months could join the federal pool, while those who could not would retain or join the state pool, leading to a generally sicker pool of enrollees in the state pool.

States that already have guaranteed issue and modified community rating in their non-group market–A number of states, including New York, Maine, Vermont and several others have already eliminated pre-existing condition exclusions instead of having a high risk pool. However, because of the six-month no-coverage requirement it’s unclear if these states would benefit at all.

Regulations for how states should implement the HRP provisions are expected very soon from HHS, but it’s unclear whether the Secretary has the authority to address these problems, or if the solution requires a Congressional fix.

Coming next time: Repeal Watch!

–Michael Miller, director of strategic policy

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Insider Update: Summing up the Summit

Friday, February 26th, 2010

After seven hours of debate, parties agree to disagree on whether they are close to agreement

As expected, no new consensus emerged yesterday from the seven plus hours of debate between top Congressional Democrats and Republicans and the President about what was wrong with the nation’s health care system and how to fix it. Despite the Democratic mantra that “we’re not that far apart,” what did emerge was greater clarity about exactly where the differences lie and why they cannot be bridged.

First, there is a fundamental difference between the parties on the issue of how to address problems in the health insurance industry. The proposal being advanced by President Obama and Congressional Democrats contains a strong program of insurance reform including:

  1. Eliminating pre-existing condition exclusions
  2. Setting minimum standards for coverage
  3. Requiring insurers to spend at least 80% of the premium dollars they collect on health benefits
  4. Prohibiting insurers from charging people more because they are sick (or because they are female) and limiting variation based on age
  5. Increasing the ability of state and federal regulators to block excessive and unjustified rate increases

In stark contrast, the proposals advanced by Congressional Republicans would give insurers increased ability to create pools of healthier enrollees, which would lower costs for some but would result in higher premiums for people who are older or sicker.

Anyone? Anyone?

The second major difference is on coverage. According to the Congressional Budget Office, the president’s plan would reduce the number of uninsured by more than 30 million people while the ideas offered by Republicans would insure only around three million (Community Catalyst’s latest paper explores these issues). The President might as well have been the teacher in “Ferris Bueller’s Day Off” given the deafening silence that followed when he asked if there was any way the Republicans could see themselves moving beyond the minimal coverage expansion in their plan.

At the close of the summit, President Obama offered to continue the dialog with Republicans but with the precondition that they rethink their position on these two key issues. House and Senate Republican leaders were quick to decline the invitation, leaving only one path to real reform: Democrats in Congress have to come together to pass a bill by majority vote; the sooner the better.

Moving Right Along

Over the next few days House and Senate leaders will need to consult with their members and with each other to lay out the parliamentary path forward. This “inside baseball” will have to get worked out by the House and Senate leadership and the White House. What matters most is not the sequence, but the outcome.

Keep fighting the good fight

Advocates need to continue to make the case for comprehensive reform. You can help by signing this online petition that is being sponsored by the American Cancer Society/ Cancer Action Network, Community Catalyst, and many other national organizations:
www.healthcarepetition.org/10707_communitycatalyst

-Michael Miller, director of strategic policy

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The dam breaks, PLUS the votes are in! The Insider’s Naughty and Nice pol(e)

Monday, December 21st, 2009

By reaching a compromise with Sen. Ben Nelson (D-NE) (we’ll talk about how below), Senate Majority Leader Harry Reid has cleared the last major obstacle to historic passage of health reform in the U.S. Senate.

If all goes according to plan, the Senate will vote for passage of the Patient Protection and Affordable Care Act (PPACA) on Christmas Eve, putting the United States on the verge of enacting a major historic overhaul of health care financing and delivery and setting the stage of an intense round of negotiations between the House and the Senate over the shape of a final package.  (We’ll focus on those House-Senate negotiations next week).  The expected schedule of votes is as follows:

•    Monday 1 AM: add the “Manager’s amendment” to the underlying PPACA proposal (passed 60-40). See Community Catalyst’s reaction to the vote here.
•    Tuesday 7 AM: replace the underlying “shell bill” with the PPACA (60 votes needed)
•    Wednesday 1 PM: agree to stop talking and take a final vote (60 votes needed)
•    Thursday 7 PM: Vote on final passage (51 votes needed)

The Manager’s Amendment

The Manager’s Amendment includes a number of other improvements to the underlying bill including stronger accountability and transparency provisions for health insurers, a new approach to national plans overseen by the Office of Personnel Management (the same office that oversees the Federal Employee Health Benefits Plan) stronger cost containment provisions and improved coverage for children.  Click here for CC summary of the key changes.

An agreement was also struck with physicians to do a two month patch on Medicare physician payment rates (as an amendment to the Defense appropriations bill) that would otherwise be cut Jan. 1 with the understanding that after the recess Congress would come back and work on a longer term solution.

The key to locking down the 60th vote for heath reform in the Senate was finding language that would be acceptable to both anti-choice Sen. Ben Nelson and pro-choice Senators represented by Senators Boxer and Murray. (Sen. Casey from Pennsylvania was the other main party to the negotiation).  The main elements of the proposed abortion compromise include giving states the right to determine whether abortion coverage will be available in their state exchanges, strict segregation of federal funds, and additional support for adoption and for pregnant teens.

The agreement was struck despite the opposition of virtually all outside advocacy groups on both sides of the abortion debate.  Setting the stage for conflict down the road, both Congressman Stupak (who authored the abortion restriction in the House) and Congresswoman DeGette (who leads the House pro-choice caucus) have voiced concerns about the Senate language.

Naughty and Niceelf-list
The results of the Insider’s holiday naughty and nice poll are in.

In the naughty category, Sen. Joe Lieberman of Connecticut won by a landslide, easily eclipsing interest group leaders and other political figures. While Lieberman was not unique in his opposition to the inclusion of a public insurance option as part of reform, he angered proponents with his inability to articulate any consistent or fact-based basis for his opposition and perhaps equally for his flip-flop on a proposed Medicare buy-in that was advanced as a possible compromise.  Historically, Lieberman has been a supporter of the Medicare buy-in and appeared unable to give a coherent reason for his last-minute switch.  There was a late surge for Sen. Ben Nelson, but there’s no doubt who Insider readers regard as health reform Public Enemy Number One.

In the nice category, the winner was Hill staffers.  The vote reflects the experience of Insider readers who are mostly health reform advocates and activists.  While Senators and Congressmen get the headlines, a small group of Congressional staffers have worked countless hours to make reform happen.  They are truly the unsung heroes of health reform, and the Insider is happy to give them a shout out for their incredible dedication.

The other leader in the nice category was the late Senator Kennedy.  Though illness and untimely death kept him from exerting as much leadership in the debate as we’d come to expect from him over the years, Insider readers agreed that Kennedy remained the guiding spirit throughout the debate.  Final passage of reform will be an enduring monument to his tireless work over the decades to secure health security for all.

Jon Stewart also polled strongly in the nice category.  There have been many times when we desperately needed laughter at the inanity of the debate, and Stewart has probably done more than anyone else to highlight the frequent absurdities. (His panel discussion on death panels—should they be public or private and available to all or only through the exchange—is one of my personal favorites).  The Insider editor also gives an honorable mention in the nice category to Ezra Klein and Jonathan Cohn, two journalists whose blog coverage of the debate has been consistently excellent.  Hope Hanukah Harry was good to you guys.

The Great “Is it Worth it?” Debate or Two Cheers for Health Reform

A Health Reform Quiz:

Is the PPACA
a)    a great bill
b)    a terrible bill that is little more than a giveaway to private insurers
c)    a terrible bill that is a government takeover of the health care system that will explode the federal debt
d)    a flawed bill that nonetheless does a lot of good and must be passed

Depending on which health care “team” you play for, you’re likely to pick your answer from a-c. Senate Democratic leaders and their loyal supporters among some advocacy groups pick “a” (some of them really think the answer is “d” but aren’t allowed to say so), disappointed activists on the left pick “b”, and the (mostly Republican) opposition and certain special interest groups pick “c”.   But the truth—as best as I can determine it and as honestly as I can answer the question—is “d.”

Why isn’t the right answer “a”?  First and foremost, although the Senate bill does a lot to make coverage and care more affordable, it doesn’t do enough.  A person can drown in six feet of water or 60, and many low- and moderate-income families will still find the premiums and cost-sharing requirements in the Senate bill to be a significant financial burden that could limit their ability to access health care or threaten their ability to afford other necessities. Legislation passed in the House does a much better job of making coverage and care affordable for those most likely to need help.  And while there are many improvements in insurance oversight, there are still some troubling loopholes that could undermine the effectiveness of the new insurance exchanges as a tool for driving down costs and holding insurers accountable.

Finally, due to their inability to agree on adequate financing, the Senate bill takes too leisurely approach to reducing the number of uninsured.  It’s worth noting that when Medicare passed in 1965, benefits started the next year.  When Massachusetts enacted their groundbreaking reform in 2006, a major expansion of coverage was underway within six months.  In the Senate bill, it takes four years for the major coverage provisions to kick in.

Both Senate Finance Committee Chair Max Baucus and Senate Majority Leader Harry Reid have spoken eloquently about the toll of preventable death, not to mention the financial damage and anxiety caused by our current system.  Yet these problems will continue essentially unchecked for four long years because Senators could not agree on a more robust financing package.  In fairness, some of the responsibility for this slow motion reform must also be laid on the President’s doorstep—a result of his mysterious insistence that the “cost” of reform not exceed $900 billion over 10 years even if fully or more than fully offset with new revenue and savings. Keeping under the $900 billion threshold is part of the reason why it takes reform so long to get going.

Certain corners of  the left claim that the bill is nothing more than a giveaway to insurers or that that the proposed excise tax on high cost health insurance plans is unfair. The first criticism is an exaggeration triggered largely by the disappointment around the public plan. While removal of the public plan is a real loss, basing support for reform on this single issue ignores the substantial good the bill would do (see below). The second criticism also has some merit, but the objection should not be enough to scuttle the bill. Though there’s every reason to think that there are better ways to control health care costs than taxing benefits as an incentive for people to have less comprehensive coverage, the reform proposal is hands down fairer than the status quo, even including the benefit tax.

What about the criticism from the right?  For the most part, it has no more reality to it than the death panels of summer did.

Health care is complicated, health reform is complicated and forecasting the future is far from an exact science.  So it’s possible the Congressional Budget Office (CBO) made mistakes in assessing the impact of the bill on the federal deficit, but it is just as likely that they have underestimated as overestimated the effect.  Despite its limitations, the CBO is the best umpire we have available.  Critics who were all too happy to cite earlier CBO analyses that supported their case look hypocritical now as they reject CBO findings that show that the Senate bill will substantially reduce the federal deficit over time.

And if prohibiting insurers from rejecting people because they have a pre-existing condition or keeping them from ratcheting up premiums to force people who file claims to drop coverage, or creating some transparency and accountability in the industry constitutes a government takeover, then bring it on, I say.  Defense of the status quo is unconscionable.

Why pass reform despite its flaws?  First, as I’ve said, because the bill is simply no where near as bad as its critics on the left and right would have it.  It is imperfect but it does a lot of good, such as elimination of pre-existing condition exclusions, a prohibition on charging people more based on gender or occupation, limits on how much more they can be charged based on age and much more. Here’s our short list of the good stuff.

Not only that, but there will be time and opportunity, as well as the necessity, to correct flaws as we go along.  Consider Medicare Part D.  The program as passed was considered with substantial justification, to be a giveaway to the insurers and drug industry.  It is also overly confusing and inefficient.  Nonetheless it provides important help accessing prescription drugs for millions of Medicare beneficiaries.  Moreover, substantial improvements in the program are being contemplated now as part of reform, and there is no reason to suppose that additional improvements to PPACA cannot be made in the future.  So has it been with Medicare and Medicaid, and so will it be with PPACA.

Like we wrote last week, every victory is partial and impermanent. It must be both defended constantly and built upon.  If the history of health reform teaches us anything, it’s that while incremental progress is possible often, the chances for big change are rare, and we should take them.   If we wait for the perfect, we will wait forever.

Those who want to provide health security for all but who counsel starting over not only undervalue the improvements that reform will make, but also underestimate the difficulty of starting over and the damage that would be done to millions of people in the meantime.  As a rallying cry, “Pass this legislation despite its flaws” may not be that inspiring, but it fits the imperfect world we live in, and captures the imperative before us.

Let’s get this bill passed and then get to work making it better.

–Michael Miller, director of strategic policy

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The New Nattering Nabobs of Negativity

Thursday, December 17th, 2009

So Howard Dean has joined the ranks of liberals piling on health reform and encouraging lawmakers to toss in the towel. (See Kos and Firedoglake for more reform-flogging from the left.)

Health reform does not succeed or fail by the public option, despite what Dean and others seem to suggest. This is not to say that the public option wasn’t important—at least as it was originally imagined (see Michael’s post here.) But we and others like Jonathan Cohn have pointed out the success of reform ultimately depends on strong subsidies, insurance reform and improvements in care delivery—things that are still in the bill.

Perhaps it’s because they hitched their wagons so closely to the Obama’s Technicolor campaign and the ’08 election that Dean, Kos and Co. feel such betrayal in the real-world policy give and take happening in the final stretch of health care reform.  And I’ll admit, it’s easy to see how eight years under the Bush administration could lead one to believe that everything is a black-white issue.

But that kind of thinking—a rugby-like mentality in which health reform is a game with a scoreboard—fails both the spirit of reform and the work that’s been done.  By dismissing health reform with such invective, Dean, Kos and the choir of liberals singing their tune haven fallen to the very same faulty syllogistic thinking they shun the “teabaggers” for: Giving any ground is akin to surrender and defeat, and the yield of such defeat must therefore be waste.

But it’s not.  It’s important to see how far health reform has come, within a year of an administration for whom reform was nearly always a dirty word. If, under the Bush Administration, we could have gotten any one of the things that are in the reform packages now – federal matching funds for all low-income people, say, or a ban on pre-existing conditions exclusions – the champagne would have flowed on the Left bank.  But now, the public option is out and folks are headed for the hills.

Far from the “so-called reform” Kos rolls his eyes at, the improvements this bill will make are real: Expanded coverage to hundreds of thousands of people who now go uninsured, critical insurance reforms that will protect American families from losing coverage and medical debt, subsidies to help people buy coverage who can’t afford to now, and innovations in the way the systems delivers and assesses care. Yes, it’s flawed. It doesn’t give low-wage workers help and health security fast enough, for instance. But it gets people help, and binning the whole thing and starting over leaves those people stranded.

Health care reform may have been a presidential campaign promise of Obama’s, but it wasn’t by bashing insurers that the candidates won support for health reform – it was because they were offering to help people who desperately need it.  Health care, despite what some of the news networks insist, is not a Democratic or Republican issue. It’s about helping people. It is about starting to mend a really broken system, and beginning to re-imagine how a country takes care of it’s sick and frail. To try things out and see what works. And it’s sure not a panacea. But when was it ever going to be?

All victories are partial. The Voting Rights Act was a victory by any standard, but it didn’t stop racial discrimination in the U.S. – it made way for a succession of other, smaller victories that helped turn back systemic racism. Passing Medicare was a victory – but not all at once. Coverage for the disabled, and the drug benefit, came later, and this bill continues those efforts to make the program work better. Despite the suggestions of these critics, it’s near impossible to get a project as complex and all-encompassing as reform right on the first try. But we need to make a first try, and the Congress recognizes that.

The flaws and compromises in the health reform proposals are not reason to dismiss them but to instead commit to the process of reform and the act of helping people. We should enact the best bill possible, then start working to make it better. Those bent on merely measuring the gap between Perfect Health Reform and what the Congress is working on now are selling their country short.

–Kate Petersen, Health Policy Hub

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218, that elusive magic number

Monday, November 2nd, 2009

House prepares to bring a strong reform package to the floor
On Thursday, House leadership unveiled a strong health reform package and plans to begin debate on it late this week.  The House bill gelled in the middle of last week when leaders judged that a final push to get 218 votes for a bill that included the “robust public option”—a public insurer that would pay rates based on what Medicare pays—was going to fall short.

Instead, they put out a bill that includes a public insurance plan that would negotiate rates with providers.  The CBO projects this version would save less money, so Leadership made up for the lost savings by proposing a further expansion of Medicaid to 150 percent FPL instead of the 133 percent that cleared committee in the original bills.

Community Catalyst is strongly supportive of the House bill, which goes beyond earlier drafts in a number of respects. It includes a national insurance Exchange that also gives states the option of creating their own Exchanges, new rules that prevent insurers from denying coverage to people with pre-existing conditions or charging people more because they are sick, expands Medicaid, adds a long-term care insurance program for disabled adults, requires health plans to allow young people through age 26 to remain on their parents’ policy, and eliminates the Medicare doughnut hole by 2019, rather than 2024.

Compared to the bill taking shape in the Senate, the House bill is likely to provide better benefits, better subsidies and more progressive financing while reducing the federal deficit and still costing less than the $900 billion ceiling set by President Obama.  Compared to the Senate, the House leadership appears more willing to take on segments of the health care industry and also includes a more significant employer responsibility provision.  (As a result, it faces stiffer opposition from these interest groups, though insurers are opposing the Senate bill as well).  However, according to some analysts, the House legislation does less to reduce spending over the long run than the proposal that passed the Senate Finance Committee.

While the House bill represents a huge step toward quality affordable health care for all, it includes a couple of notable weaknesses. The bill bars most workers who have employer-sponsored insurance from receiving subsidies in the health insurance Exchange.  Instead, workers would be required to take up their employer offer of coverage unless its cost exceeds 12 percent of their income, a requirement that would be too burdensome for low-wage workers.  A better approach would be to exempt workers from the mandate requirement on a sliding scale, as Massachusetts does.

A second problem is that the House legislation assumes that coverage is “always affordable” for people whose income exceeds 400 percent of the federal poverty line.  This provision would be burdensome, especially for older adults with income just above the cut-off point for subsidies.  Although the bill limits premium variation based on age, an older person could still pay twice as much as young adult, leaving them with a very substantial premium liability. Establishing a ceiling on how much people could be required to pay for coverage, regardless of income, would remedy this problem.

The House bill also eliminates the Children’s Health Insurance Program, known as CHIP, and assumes that children who are not Medicaid eligible will get their coverage through employer plans or through the Exchange.

There a number of potential benefits to moving children off of CHIP, not least of which is moving away from a block grant program that gives states the ability to offer relatively limited coverage (flexibility that states have not generally utilized to date) and instead give children a federal guarantee of coverage.

But while under law, CHIP plans may be limited, in practice most states have provided kids with comprehensive coverage.  As a result, children transferring from CHIP to Exchange coverage could see their benefits reduced and their costs increase.   Preserving CHIIP as a program that provided additional benefits and cost-sharing protections for children in families above the income eligibility threshold for Medicaid could help ensure that children get the health care they need.

For more details on the House bill see this updated Community Catalyst summary and discussion.

218, that elusive magic number
As the House prepares for floor action as soon as this week, several hurdles to passage still stand.  Here are the three main sticking points:.

•    Abortion
A number of House Democrats, led by Michigan Representative Bart Stupak, want to have a vote on language that would preclude plans that receive federal subsidies from including abortion coverage.  The current language in the House bill separates out the cost of abortion coverage from a benefits package, and requires the value of subsidies to be calculated without it. But Stupak wants a stricter prohibition on abortion coverage and claims to have the support of 40 House Democrats, which could be enough to block reform if they do not get their requested vote.

•    Immigrant Coverage
A debate is simmering within the House about whether to adopt a provision, favored by President Obama, that would prohibit undocumented immigrants from buying insurance coverage through the Exchange, even with their own money.  Many progressives, especially members of the Congressional Hispanic Caucus, are concerned about the lack of equal treatment for legal immigrants.  Advocates and lawmakers are now contemplating whether to push for an amendment that would give states the option to receive federal matching funds to cover certain legal immigrants through Medicaid.

•    Public Option
While the House leadership believes they lack the votes for a public option tied to Medicare rates, some progressives still want a chance to vote on that amendment and may block action if they don’t get it.

All of these issues could be addressed in a “manager’s amendment” or in the rule that will govern debate in the House later this week.

Affordability woes in the Senate
In case you missed it in our Friday blog post, the Senate is still struggling with the affordability issue.

While sources on the Hill confirm that the Senate is trying to make badly-needed affordability improvements for moderate-income households, they are trying to do it while still reducing fees paid by medical device manufacturers and an excise tax on high-cost insurance plans.  As a result, the best idea the Senate appears able to come up with at this point is to reduce premiums for moderate-income households by raising them for those at the bottom (We compared this proposal with the SFC bill and House leadership plan here.)

Timetable Update
House: The House plans to start floor debate late this week and to finish no later than Thanksgiving.

Senate: A backlog of work at CBO has slowed progress on the Senate side.  Given the slower pace of debate in the Senate, and with Veteran’s Day and Thanksgiving on the holiday horizon, the Senate is unlikely finish debate this month, though there is still a good chance they will finish before Christmas.  That means though, that resolving the differences between the House and the Senate will likely extend into next year.

Shameless plug department

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–Michael Miller, Director of Strategic Policy

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