Tuesday, November 24, 2009
Thursday, November 19, 2009
I've read all of the portions of the Bill that directly affect patients (skimming sections on things like data collection and health care workforce development), and I'm impressed by how good a job Senator Reid seems to have done at synthesizing the Senate HELP Committee and Senate Finance Committee Bills, while also anticipating some of the differences between the Senate and the House versions.
As is true of all the plans, Senator Reid's would eliminate pre-existing condition exclusions, cancellations of policies based on health status, lifetime maximums, or premium rating based on health history or gender. Also as in all of the other plans, an insurance "exchange" will be established where you can shop for insurance, see the available alternatives, and weigh your options. Among the options is a public option -- a plan run by the government that will be available as an alternative to private insurance if the patient chooses -- that will allow states to opt-out if they wish. In addition, the Bill would allow the creation of nonprofit co-ops. Further, states can create a program for low income individuals not eligible for Medicaid, and Medicaid is expanded to include anybody with income up to 133% of the federal poverty level. Multi-state compacts are permitted, along with nationwide plans with state opt-outs.
While most of the changes will be effective in 2014 (one year later than the House plan), immediately, there will be a national high risk pool for people with pre-existing conditions who have gone without insurance for at least 6 months.
There are limits on out-of-pocket costs -- deductibles are limited to $2000 for an individual and $4000 for families. Other cost sharing -- copays and coinsurance -- are limited to the same limits as apply to health savings accounts -- right now, according to the IRS website, $5600 for an individual and $11,2000 for a family. These out of pocket limits are decreased on a sliding scale for people with incomes below 400% of the federal poverty level. There are tax credits that are calculated based on a formula that, frankly, is so complicated that I can't tell you what it means, but it is tied to (1) the cost of plans in the Exchange; and (2) household income. People with incomes up to 400 percent of federal poverty level would be eligible for a tax credit. Premiums are capped at 9.8 percent of income.
Individuals would be required to have insurance, but the penalty for not doing so is very small, starting at $95 per year, and increasing over time to $750. There is no requirement that employers provide insurance, but employers with 50 or more employees will have to pay a fee of $750 for each employee who is not covered who receives a tax credit. There also is a small employer tax credit for employers with 25 or fewer employees.
Medicare improvements include a reduction of the "doughnut hole" by $500 and 50% discounts on name brand drugs for low and middle-income consumers. Rates paid to Medicare Advantage Plans are decreased to match what the government pays for the same coverage.
In addition, there is a mandatory appeal process, including both internal and external appeals, applicable to all plans included in the Exchange, and there will be a uniform appeals process for Medicare Part D plans.
To pay for the plan, there will be a series of taxes. First, so-called Cadillac plans -- plans that cost more than $8500 for an individual and $23,000 for a family -- are taxed at 40%. Further, the Medicare tax will increase from 1.45% to 1.94% for people with income over $250,000. In addition, there are the penalties mentioned above for failing to obtain insurance, and for employers who don't cover employees who get tax credits. In addition, there is a 5% tax on elective cosmetic procedures -- procedures necessary to correct congenital deformities and so on are not subject to tax. in addition, every health insurance policy and every health insurance plan, including self-funded plans, will pay $2 per covered person.
Those are the highlights. It's very similar to the House bill in many respects, although the House has a so-called millionaires tax, larger penalties for individuals who don't buy insurance, and larger penalties on businesses who don't provide insurance.
There are, of course, some sticky issues remaining. Rather than prohibiting all plans in the exchange from covering abortions, even with the woman's own money, the Senate version segregates the federal money from private money and allows insurers to cover abortions as long as the woman's own money is used. Illegal immigrants are not covered at all.
That's the summary. Of course, you are welcome to read the whole thing here. There's also an excellent comparison of the House and Senate versions by the NY Times here.
Please note that I will be taking a short break from blogging. I'm having a small hernia repair tomorrow. It's not a big deal, but I'll be out of commission for as long as I'm on pain meds and could say something stupid!!! Take care of yourselves in the meantime. Jennifer
Wednesday, November 18, 2009
Just more scare tactics from those who want to stop health insurance reform. Jennifer
Tuesday, November 17, 2009
Friday, November 13, 2009
Wednesday, November 11, 2009
I have gastroparesis. My gastric emptying test shows 0% emptying after 90 minutes. What goes in just sits in my stomach for hours and hours. Without two medications -- Reglan and Protonix -- I either don't eat at all, or I vomit. A lot.
My insurance company, Anthem Blue Cross Blue Shield of Connecticut, doesn't want to pay for Protonix. For my $1000 per month premium, they want me to take Prilosec, Prevacid or Nexium instead. Anthem gets a better price on those meds. So once a year, they require that my doctor prove to them that I really, really need Protonix.
Last month, I filled my prescription. The label on the bottle said I had 2 refills left, so I didn't give it another thought. This week, I went to refill my prescription and it was denied. I need prior authorization for Protonix.
It's not like we didn't go through this a year ago. And it's not like anything has changed since then. But they make me jump through these hoops anyway.
I've tried all of the other meds. In fact, if Anthem would check its own records, it would see that it paid for them!!! If I proved to them a year ago that I've already tried those meds, then I've still already tried those meds this year. History doesn't change.
Next, Anthem wants to know why I need two Protonix a day rather than the usual one. A year ago or so, we tried to decrease the Protonix because it might also cause diarrhea, which is a problem due to my Crohn's disease. I immediately started vomiting. We told Anthem that a year ago. They want to hear it again.
Insurance companies won't let you have more than a 30 day supply of meds, so when it's time for a refill, it means I've just about run out of my meds. And I'm traveling this week-end, so not only am I going to run out, but I am going to run out far from home. Apparently, Anthem would rather that I end up in an emergency room hundreds of miles from home than give me enough medication to get me through the week-end, while they take their time processing a request for prior authorization that says NOTHING different than the one they approved a year ago.
Patients come to me expecting me to be able to fix this insanity. After all, I read all the time that one of the biggest problems with controlling the cost of chronic illness is that patients are non-compliant with medication regimens. I'm not non-compliant. I'm trying to take my meds; my insurance company apparently WANTS me to miss my meds for several days between the time I run out and they time they get around to reviewing my request for prior authorization. By then, I will be vomiting. By then, my illness will be out of control. I'm not non-compliant; my insurance company is.
And the worst of it is that I have absolutely no power here. None. I have good contacts at Anthem -- their lawyer, the head of their appeals unit. I have a friend at the Attorney General's Office who does health insurance work for consumers. I have all of the medical information and completely, totally understand what's going on here. And none of that does me a bit of good. Because I still don't have my medicine. I'm still going to get sick.
I know the rules, so I play by them. But why didn't Anthem tell me last month that I would need prior authorization this month so it could have been done in time? Why won't Anthem give me enough medication to get through the week-end when they know full well that I'm going to run out of meds and get sick? There is NOTHING I could have done differently, NOTHING my doctor could have done differently, that would have avoided this.
And nothing in health insurance reform is going to fix this sort of thing. Congress isn't even trying to address issues like this one. Indeed, our NIH study is showing that these sorts of coverage issues are the biggest problems people are having with insurance. Even when you have insurance, you pay your premiums, you do everything right, insurers can pull the rug out from under you whenever they like. And it's legal.
In the end, if I land in an emergency room because I'm vomiting a lot and can't keep anything in me, it costs Anthem more money than it would have cost them for my medicine. But saying that assumes the system is rational. And it's absolutely not. Jennifer
P.S. -- I GOT IT. It took relentless badgering of the insurance company, but they finally agreed to expedite the review and then they granted the authorization. It took about 2 hours yesterday and 2 hours today on the phone to make it happen. Had I not been going out of town, this definitely would have carried over to next week. Lesson: don't ever take no for an answer! J
Tuesday, November 10, 2009
Monday, November 9, 2009
First, in order to get the win, Speaker Nancy Pelosi had to allow an amendment that will prevent any woman receiving a federal subsidy to have an abortion covered by her health insurance policy. The effectively means that the plans offered in the exchange -- essentially all plans for individual and small to mid-sized employers -- will not cover abortions. Only about 13% of abortions are funded by private insurance, so this was more of a symbolic vote than one that will make abortion unaffordable and, thus, even more rare. But what bothers me most is that it makes abortion even more of a class-based issue. If you had enough money to afford a privately-funded abortion, you probably won't qualify for a premium subsidy for your health insurance. In other words, the people who will receive subsidies are the people least able to pay for abortions, and those are the ones whose insurance will not be allowed to pay.
And if you watched any of the coverage over the week-end, you also know that male Republicans shouted down every woman in the House who tried to make comments about the impact health reform will have on women. No woman could get past a sentence. If I can find it again, I'll post it here. It was quite upsetting. It's bad enough that there are only 17 women in the House today. Those who are there were censored, and that was wrong.
Even more wrong is the fact that the Senate still doesn't have a bill or Congressional Budget Office estimates. Joe Lieberman and some of his misguided cronies have said that they will not allow a bill with a public option to even come to a vote. It's one thing to oppose; it's another thing to refuse to let something come to a vote. The way I count it, that's two acts of censorship.
I watched the HBO movie about Obama's campaign over the week-end. It made me recall the optimism I felt when he was elected, the tears of joy that flowed while I watched his inauguration. It's been 9 months, and now we have posters comparing health reform to the Holocaust, Obama in white-face, with a Hitler mustache -- where is this mean-spirited, small-minded, right-wing insanity coming from? And how is it that this fringe -- this small group of ultra-conservatives -- have taken over the Republican party and been given a voice that they now are using to censor dissenting opinions?
Health reform passed a major hurdle on Saturday night, but it is nothing like the hurdles that remain. I will be very surprised if we get any public option out of the Senate, and if Senator Reid doesn't hurry, we may get nothing at all, at least until the 1st of the year, which will give the Tea Baggers another shot at members when they are home for the holidays -- more scare tactics that seem to have worked against conservative Democrats in the House, and will be even more effective in the Senate.
And I am literally sick over the fact that a Senator from my state -- a state that has gay marriage, that is generally among the most liberal -- has pledged to shut down health reform in the Senate if it contains any form of public option -- even one with a trigger or an opt-out or an opt-in. Joe Lieberman will never be elected dog catcher again in Connecticut after this. But that doesn't change the fact that he -- that any one of 60 Democrats (and 2 Independents who vote with the Democrats) -- has veto power over the future of health care in America.
Where did the optimism go? Where are all the young kids who supported Obama? Why do the Tea Baggers go unresponded to? Why are the liberal Democrats sitting on their hands? Why are ANY Democrats hedging over the need to provide life-and-death health care to all? Indeed, why are any Americans against it?
I understand the fear of big government. But it's, frankly, a stupid argument in the health care context. We already have the federal employee plan, the VA, Medicare, Medicaid, coverage of all prisoners (state and federal) -- plus state employee plans, county plans -- and regulations that exist in EVERY state regulating health insurance. This is not about a government take-over; it's about a change in the substance of the government position. Why isn't that totally obvious to everyone?
I watch and listen in amazement. Are people really so poorly informed that they don't know that insurance already is regulated? Do they really believe that health care is not already rationed by health insurance companies (not to mention the government plans listed above)?
If you believe these things, then you need education. Now. I beg you -- urgently -- to read, listen. Talk to someone you know with a chronic illness and ask them if health care isn't already rationed by insurance companies. Email me and I'll send you a link to your state's insurance regulations.
This is too important an issue to shoot from the hip. If you are buying the Tea Baggers, it's because you are lacking information. If you want to be informed, there are thousands of us out here trying to get you that information. All you have to do is take the time. This isn't about politics. It's not about abortion. It's about life and death. Of our citizens. Of our Nation. Jennifer
Sunday, November 8, 2009
Friday, November 6, 2009
Why have I avoided the issue? I have tried to keep my former life as a pro-choice advocate separate from the work I do with Advocacy for Patients just because the abortion issue is so highly charged with politics and rancor. Although I have participated in the Connecticut Women's Health Campaign and supported efforts to protect women's reproductive health, the truth is that reproductive rights simply have not come up in the work I do on behalf of the chronically ill.
I've seen so much misinterpretation and misrepresentation around health insurance reform that I feel I have to at least make sure that you know what the issue is and what proposals are on the table to address it.
Under current law made by the Supreme Court many years ago, the federal government is allowed to prohibit the use of federal funds for abortion. Nobody -- NOBODY -- is trying to change that in the course of health insurance reform.
The issue, though, is how to ensure that federal insurance premium subsidies, and any public option, are not used to fund abortions.
The Catholic church would like to prohibit any insurance plan sold through an insurance exchange (the marketplace that will be created where you can shop for insurance) -- including private plans, including for people who do not receive any federal subsidy -- from covering abortion. This clearly is broader than just prohibiting the use of federal funding to pay for abortions. So both the Senate and House bills try to create a way to segregate federal subsidy money from the private portion of insurance premiums and ensure that only private money is used to fund abortions.
Abortion opponents say any compromise will not guarantee that no federal funds are used to pay for abortions. Abortion rights advocates say there has to be a middle ground because a woman has a right to pay for insurance that will cover abortions with her own money.
The compromise that has been offered by Rep. Ellsworth would require that the exchange hire private contractors to administer all payments for abortion under any plan sold through the exchange to make sure that only private money is used for this purpose. As of this morning, the Catholic Bishops have said that this still isn't good enough. It's not clear what, if anything, will be.
And this is the hang-up. It is NOT the case that ANYBODY -- even Planned Parenthood, et al. -- are trying to get abortions paid for by federal money. Everybody, including Nancy Pelosi, agrees that we're not going to try to change the law on abortion funding through health insurance reform. That's a fight for another day. But pro-choice members of Congress do not want to use health insurance reform as a way to ban all abortions, either.
The issue is whether they can find middle ground. I surely would hate for this to be a major hang-up when so very much is at stake. Jennifer
Thursday, November 5, 2009
The House is just days away from voting on comprehensive health reform. With special interests stopping at nothing to block reform, your personal stories send a powerful message to Congress.
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No, I don't. And here's why, from this morning's Politico:
“The civil rights community, Whitney Young, Roy Wilkins, Martin Luther King Jr. — all these people were for a big, comprehensive Civil Rights Act,” Clyburn told the caucus. “Johnson realized he couldn’t get in one fell swoop all that they were asking for and made it very clear to them in the negotiations: ‘If you want me to put this bill on the floor, I’ll put the bill on the floor, but it’s not going to pass. If you want to pass something, then we have to go into this bill to see what will pass.’”
The voting rights provisions came out and didn’t pass until 1965, after the presidential election. And while the 1964 law outlawed discrimination in the private sector, it wasn’t until 1972 — when Clyburn was on the staff of a South Carolina governor — that the same requirement was imposed on state and local governments, which had resisted the federal mandates.
“I didn’t want anyone to think that if you don’t get everything you want in this health care bill right now, that’s the end of the game,” Clyburn said. “What we need to do is lay a foundation. Get passed what we can pass that will have a meaningful impact on people’s lives — not put too many of our people in jeopardy — and then build upon it later. It’s a long road."
Yes, it is a long road. It's been a long road. Martin Luther King railed against injustice in health care in the 1960's. Lefties have been talking about universal healthcare as long as I can remember. The Clintons did their best in the 1990's and we lost -- perhaps in part because we strove for perfection, for the total fix.
I am in favor of single payer universal healthcare -- period. No exchange. No public option. No premiums. No subsidies. No managed care. None of it.
But I will support -- indeed, cheer -- whatever we get this time around. If we just get rid of pre-existing condition exclusions and lifetime caps, things will be better. If there are caps on out of pocket expenses, that would be very good. Subsidies for the middle class and expanded Medicaid will go a long way towards covering the uninsured.
Will insurance still be too expensive? Yes, it will because Congress is not prepared to go toe to toe with the insurance lobby or the pharmaceutical lobby or the health care provider lobby. We are not going to get it all done this time.
But what we do get done will be a step in the right direction -- a big step, a first step that makes next steps pretty inevitable.
I don't need perfect. I just need progress. Jennifer
Tuesday, November 3, 2009
According to today's NY Times:
Under the House bill, the budget office said, a family of four with income of $78,000 in 2016 would pay, on average, an annual premium of $8,800 and co-payments of $5,000, for a total of $13,800, equivalent to 18 percent of the family’s income.
A family of four with income of $90,100 could also receive subsidies. It would pay $11,100 in premiums and $5,500 in cost-sharing, for a total of $16,600, or 18 percent of family income, the budget office said.For lower-income people, the subsidies would be more generous. A family of four with income of $66,000 would pay premiums of $6,300 and cost-sharing of $3,700, for a total of $10,000, or 15 percent of its income in 2016, the budget office said.
That worries me a lot. Don't forget that I think that's gross income compared to actual costs, so actually the families would pay a much higher percentage of take-home pay. It's better than it is today -- a $5000 cap on out-of-pocket costs is better than catastrophic losses people suffer today with hundreds of thousands of dollars out of pocket for long hospitalizations, stays in intensive care, and expensive infusion drugs. But still -- this is a huge amount of money to expect people to pay every year, year after year.
And this is why we need a less expensive public option. Because with prices like these, we are not making insurance affordable enough. People will still have to go without insurance.
Now, to answer Rabbit's questions from yesterday's post -- I'm answering them here rather than in a comment because they're particularly good questions that others probably have, too:
There's no info about whether the House's high risk pool would be priced like state high risk pools, which tend to be very expensive. The national high risk pool would be temporary, just to find a way to cover people with pre-existing conditions until the exchange gets up and running. There's very little detail about the plan, though.
The rules about pre-existing conditions will be the same no matter how many pre-existing conditions you have. Between 2010 and 2013, the existing rules, which require states to offer a guaranteed issue option if you've had insurance and you don't have more than a 63 day break in coverage, you'll be able to get insurance. And there will be the national high risk pool, as well. After 2013, when the exchanges go up, there will be no more pre-existing condition exclusions -- period. One condition or many, the rules will be the same.
I'm worried about letting states opt-out of the public option, too. We have to hope that political pressure and federal funding stop that from happening. And the new Medicaid rules, which will cover single adults with no children up to 133 or 150% of the federal poverty level (depending on whether we get the House or the Senate version), will apply in every state -- no opt-out allowed. So that's going to be a very big and welcome change.
And what's a medical home? It's a proposal for chronic care management which has a primary care doctor or physician's assistant as the person who coordinates care and is the point of contact for the patient. In the House version, it can be a specialist, too. That person coordinates care among all the specialists and makes sure that all of the patient's needs are met. The idea is that the patient will have one-stop-doctoring at the medical home, which will also hold all of the patient's medical records, make sure there are no medication interactions, etc., etc. For those of us with chronic illnesses, the medical home should simplify our lives. My problem with most medical home models is that they focus on doctors and coordinating care, all revolving around a single doctor when they should revolve around the patient. But that may come as more of this pilot projects get under way.
And finally Rabbit wants to know how I'm doing. I've been talking about myself less lately, mostly because it's so important to get accurate info about health care reform out there. But I've lost 12 pounds. I have one more trip -- DC next week -- and then hernia surgery on November 20. It's pathetic, but I'm looking forward to it because it will give me an excuse to take some time off, and the week of Thanksgiving should be slow anyway.
And that's the scoop. If anybody has more questions, let me know and I'll try my best to answer them. Jennifer
Monday, November 2, 2009
For example, there would be a national high risk pool for people who can't get insurance due to pre-existing conditions. The catch, though, is that you have to go without insurance for 6 months before you qualify.
And the current rules about pre-existing condition coverage -- if you have 18 month of continuous coverage and no break in coverage of 63 days or more, and they look back 12 months to see if you had a pre-existing condition -- would be relaxed. You'd only have to have 9 months of continuous coverage and they'd only look back 3 months.
Although the public option is in the plan, it is not the "robust" public option that the liberal Dems wanted -- reimbursement rates are not tied to Medicare, but instead, they would be negotiated, so providers will do better under this version. And states could have their own plans. Even co-ops would be an option.
There's a strong pilot plan for "medical homes" that should help coordinate care of people with chronic illnesses.
There's a lot more in this 1990 page draft. I'll report back when I know more.
But another thing struck me this week-end. I was watching the Sunday talk shows and there were so many commercials opposing health care reform. I hope you're looking at who's paying for the ads. The Chamber of Commerce hates the House plan because it includes an employer mandate -- employers whose annual payroll is over $500,000 will have to provide insurance for their employees or pay a fine.
But the one that gets me is this ad that tells Seniors that Medicare's going to be cut to pay for reform. I couldn't catch the name in tiny print at the bottom of the screen, but you can bet it's related to someone who doesn't really represent Seniors. I can tell you it was a group I've never heard of before.
The truth is that the House bill helps Seniors. The House bill begins to close the doughnut hole, making prescription drugs more affordable from Seniors starting on day one. The coverage gap -- currently, drug coverage stops at about $2800 and starts again at about $4500, so that leaves about $1700 out-of-pocket -- would be reduced by $500 immediately. And the drug companies would offer discounts on drugs during the doughnut hole. This has been one of the biggest obstacles for Seniors, and the House bill starts to eliminate it right away.
And yes, Medicare Advantage plans -- plans that already deny coverage more than traditional Medicare, but which are paid more than traditional Medicare costs -- would have their costs cut. Not services; costs. Medicare Advantage plans cost the government more than traditional Medicare because they are private insurance companies and they charge higher administrative fees than traditional Medicare. So those administrative fees are being slashed. Not services; just costs. Why should private insurers get more to run Medicare plan than it costs the federal government?
The House bill is by no means final. The House will debate the bill on the floor and there will be lots of Amendments. And then the Senate will pass something and the House and Senate bills will have to be combined in conference committee. But slowly but surely, we are making progress.
If only people don't buy into those commercials. In 1993-1994, health reform failed because of the famous "Harry and Louise" commercials that were paid for by the insurance companies. Let's not be so gullible this time. Jennifer