Friday, March 19, 2010

The Health Reform End Game

This week-end, Congress begins the health reform end game. The details of the plan are now available for anybody to read here. The House will vote first on the bill already approved by the Senate with some important changes. The Senate will then vote only on the changes approved by the House. Since those changes have budget impact, the Senate will consider them under a procedure called reconciliation, which requires only a majority vote of 51 Senators, rather than a super-majority of 60 Senators. Once the Senate passes the changes, the bill will go to the President's desk to be signed. And we will be a little bit closer towards equality in health care.

The bill is far from perfect. It will be many years before we see the full effects of health reform. But within 90 days of passage, when you call me asking where you can get health insurance with a pre-existing condition, there will be a temporary high risk pool where you can get coverage right away, until the full program is up and running in 2014 and beyond.

And for me, that is really what this is all about: 30 million people who currently don't have insurance will have it. Deficits will be cut over 10 years by $138 billion. We will start to rein in the cost of health care while, at the same time, making sure that people who are sick -- people who today face tragic circumstances -- will have access to health care.

Is it perfect? Absolutely not. Will I be better off? No, indeed, I likely will be worse off. But I am prepared to give a little to ensure the well-being of 30 million uninsureds. And I am tremendously gratified and grateful to see us move off of the status quo and move towards a system that is more humane, and ultimately more affordable.

I understand that there is a lot of fear and mistrust about the reform plan. Who can really digest 2300 pages of arcane tax rules? Does anybody really know how this will all play out? Those fears are legitimate. I suspect that, as with any major piece of legislation, there will be many amendments over the coming years as the plan is implemented and honed.

But here are some things we know for sure:

1. This is NOT a government take-over of health care -- or at least no more of one than we already have. Health care in the form of Medicare and Medicaid already are run by the government. State Insurance Departments already regulate insurance companies. So all we are doing now is replacing old laws, regulations, and policies with new ones.

The primary way in which the governments (states, not federal) will be more involved in health care is the sale of health insurance through Exchanges, marketplaces where you will be able to go to see what plans are available to you, what they cost, and what will best suit your needs. Right now, most people have no clue what their options are. There are few really well-informed health insurance brokers, and few states really offer consumers a lot of information about their options that allow them to compare benefit plans and costs. This will change. You can be an informed consumer.

Second, everybody will be required to have insurance. This is necessary because, if we are going to require insurers to cover people with pre-existing conditions, we need to expand the pool of people who have insurance to include healthy people, too, thereby spreading the cost. However, Medicaid will be opened to adults earning up to 133% of the federal poverty level, and subsidies will be offered to those earning up to 400% of the federal poverty level. The penalty for not having insurance is phased in over many years, and it is very small. Small businesses will get tax credits for providing insurance, and large businesses will get penalized for failing to do so. To a large extent, then, the playing field is leveled so we can all have the same quality health care.

2. Sick people will be better off, on the whole. Once the Exchanges are up and running, there will be no more pre-existing condition exclusions; premiums cannot be tied to health history; policies cannot be canceled because you get sick; lifetime and annual caps on benefits are eliminated for new plans and phased out for old ones; children will be covered under their parents' plans to age 26; preventive care will be free.

And here's a piece we haven't talked about that is critical -- when ANY insurer denies coverage of anything, after you exhaust your right to appeal to the insurance company, EVERYBODY will have a right to an external, independent review of claim denials by an independent review organization, most likely run through state insurance departments. Today, this "external appeal" mechanism exists in all but 5 states, but it does not apply to self-funded plans. That will change; there will be independent review of all claims. The toughest appeals are won in these external appeals. This is a huge benefit to people who need new medications or who have rare or complex diseases.

Where's my reservation? There are those of us who have what have been called "Cadillac plans" -- plans that are very expensive, but that have essentially no out-of-pocket costs -- deductibles, copays, coinsurance. I have a Cadillac plan; it's what I bargain for with my employer in lieu of a salary increase. Under the new plan, Cadillac plans will be taxed out of existence, so people like me will have higher out of pocket costs.

However, even in this respect, the Bill includes limits. First, it won't happen until 2018, and I believe that there will be many new insurance options by that time. Second, the reform plan restricts the percentage of one's income that you can be required to pay on health care; above that, your care is covered 100% by your insurer. So yes, my out-of-pocket costs will increase, but not without limit.

And in the end, I evaluate public policy not solely based on what's best for me, but based, instead, on what's best for us all. And I have no reservation in telling you that this reform package is good for us as a whole.

3. Medicare recipients won't be worse off and probably will be better off. Over the next 10 years, the doughnut hole -- the coverage gap in Medicare coverage of prescription drugs -- will be phased out. That is a huge help to the chronically ill.

In addition, Medicare Advantage Plans no longer will operate as HMOs; they will have to pay for care on a fee-for-service basis. What this means is that they no longer will have incentives to deny coverage. Their premiums will be regulated so that they can't make unlimited profits off of the Medicare program. That is how we reduce Medicare costs without cutting benefits -- we eliminate profit instead of programs.


There are so many details that obviously I cannot cover in a summary. And because this is so big -- and because we (often reasonably) have come to mistrust our government officials -- I know it causes great concern and even fear. Much will only be known in the coming years as the plan is implemented.

But here's what I do know. I know that literally thousands of you have come to me for help with health insurance -- either you can't find it at all because of a pre-existing condition, or you can't pay for it, or it won't cover what you need. And I KNOW, with certainty, that in those respects, all of us will be better off.

I got a call recently from a young man with cyclic vomiting syndrome. He can't keep anything down. His teeth are literally melting. He was kicked out of the Army because of it; fired from every job because of it. He's applying for disability, but that takes months. In the meantime, he has no health care. He is about to lose his housing due to lack of funds. He all but told me that he sees his only choice as committing suicide. I tried to give him hope. I tried to make him promise to call me and talk to me and we would keep looking for answers together. But he and I both know that he is, right now, one of the forgotten. We as a society have simply decided to leave certain people behind.

The health reform plan isn't a panacea, but for this young man, there will be health care, and that means that there will be at least some answers. If he got treated and could maintain nutrition, maybe he could even work and live a decent life.

And so we choose between a status quo in which suicide -- and, less dramatically, bad health, death, and bankruptcy -- is a tragically rational option, and a plan that changes the status quo, gives people a little hope, provides real answers to some problems right away, and to many problems over the next few years. For me, the choice is an easy one.

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane." Martin Luther King, Jr. Health reform is a step towards restoring our humanity. We MUST support it. However scary it is, however afraid we are to trust politicians, however imperfect a solution this is, the alternative -- a system in which people are driven to death, ruin, and suicide -- cannot be tolerated in the America we all want to believe in. Jennifer

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