Meaning of Health Care Reform Passed

I just wanted to share a couple of blog posts from bloggers I read and respect regarding the Health Care Reform bill which was voted upon last night.

Rearranging Chairs

by Dr.Rob of Musings of a Distractible Mind

I have been asked by patients, readers, family members, and by fellow bloggers what I think about the bill passed by the House of Regurgitants Representatives yesterday. I resent this. I have tried hard to remain neutral as possible, finding equal cause to point and sneer at both conservatives and liberals. It’s much more fun to watch the kids fight than it is to figure out which one is to blame.

But given the enormous pressure put on me by these people, as well as threatening phone calls from Oprah and Dr. Oz, I will give my “radical moderate” view of the HC bill. My perspective is, of course, that of a primary care physician who will deal with the aftermath of this in a way very few talking heads on TV can understand. The business of HC is my business, literally. So, reluctantly, I take leave of the critic’s chair and take on the position where I will be a target for any rotten fruit thrown.

1. It’s not Armageddon.

We are all still alive and breathing, and will continue to do so after this law is passed and signed. The bill does not change things as radically as the shrill voices on the right suggest. It does not constitute a government takeover of HC, nor does it seem to extend any government programs by a whole lot. It is really not about HC at all, but instead about health insurance.

The goal of getting more people insured is a good one. Our system clearly (from my perspective) makes my services unaffordable – especially if you consider what people pay for procedures and medications I order. The lack of affordable insurance does harm people; I see it every day. The system is broken and needs fixing. Anyone who says otherwise needs to get a urine drug screen ASAP and then seek professional help.

Beware of the fear-mongers who make this out to be the “pro-death panel” legislation. It’s really not that bad.

2. It’s not Nirvana.

It’s actually more like the Foo Fighters…no wait, that’s another blog post.

There are folks on the Left who think that we are entering a golden age because of this. Some suggest this is the “Waterloo for the Republicans.” No, this bill is simply a rearrangement of how money is being spent, not a fount of blessings to those in need. Some people will benefit from this – especially those with no insurance – but most people won’t see a whole bunch of change from it.

This bill addresses the problem of the uninsured, but does not deal with the much more important issue of cost. If anything, it may worsen the problem that is actually at the core of the troubles: out of control spending. Figuring out how things are going to be paid without controlling what is being paid for is like rearranging chairs on the Titanic. The reason people cannot afford insurance is not because there are enough insurance options, it is because of the incredible amount of waste in the system. Agreeing to cover more with insurance without controlling cost will make the situation worse, not better.

3. The process was a national embarrassment.

The debate in DC did not seem to be about people getting the care they need; it seemed to be about which side would win. The lack of bipartisanship is a condemnation of both sides, an indication that power is more important to our representatives than is representation. Why didn’t the Democrats agree to tort reform (which nearly everyone supports)? Why couldn’t the Republicans concede that having people with no insurance is a problem the government should address?

We have a terrible situation in our country: a HC system that is out of control in its cost and that will bankrupt us if nothing is done. Yet what this difficulty has won us is not a national resolve to fix this problem, it is an increase in the partisan screaming and a worsened environment to effect real and beneficial change.

To me, the debate turned debacle is a very good argument for term-limits for members of congress.

4. It missed the point.

The real problem in healthcare, again, is not who is paying. The real problem is that it costs far too much. We are not in a crisis because of insurance; we are in a crisis because of what is being paid for by insurance. For legislation to have a real chance for fixing this problem, it must find a way to control spending.

The problem of health insurance is far easier than that of cost. Here’s why I think cost-control is going to be an even harder thing to tackle:

• There are industries making billions of dollars off of the inefficiency and waste in HC (see my post about the Sea Creatures). Devices that don’t really help people, and specialty procedures that are unproven are paid for while primary care gets the shaft. People like shiny technology and legislators have a hard time saying “no” to it – especially with the lobbyist dollars that will protect this waste-eating industry. It’s boring to promote primary care and doesn’t play well to the constituents.
• We don’t have the IT to do it. Any attempt at cost control will fail without good health IT. Doctors control a huge percentage of HC costs, yet most are operating blindly. We rely on the word of the patient for what happens in other HC settings. If you are going to expect physicians to make prudent medical decisions and eliminate waste, you must give them adequate information. Unfortunately, the current push for EMR is not about delivering information to physicians, but instead about letting doctors document more efficiently. Use IT to inform, not conform. Use IT to enable docs instead of burdening them more.
• “Rationing.” Any control of cost will be about denying care. I believe that denying care that harms patients is a good thing to do, as is suggesting cheaper alternatives if they are equal in benefit. Patients are angry when they can’t get Nexium covered by the insurance company, but OTC Prilosec is just as good for them. Patients are angry when they can’t get an MRI for their back pain when it is really not appropriate for 98% of back pain sufferers. People don’t want to be denied. Americans want an all-you-can-eat buffet of medical care. Unfortunately, any change for the positive will inevitably involve some sacrifice.

So, what do I think about the legislation? I honestly don’t think it’s that big of a deal. I think it’s good that something is being done about those without insurance, but I worry that nobody is checking the balance on the credit card. I like the arrangement of chairs on the deck, but perhaps the hole in the boat merits a little consideration.

Immediate Provisions of Health Care Reform

by Shadowfax of Moving Meat

One of the political liabilities of the HCR bill is that the most important elements -- the insurance exchanges, subsidized plans, and the expansion of Medicaid -- do not go into effect for several years, indeed until after the next presidential election. This was, lamentably, a gimmick Congress used to stay beneath an arbitrary cost ceiling imposed by President Obama. But it is what it is. So what is in the short-term horizon for health care? What effects will be seen immediately?

Shamelessly borrowing from a note that Speaker Pelosi (a close personal friend) sent me last night, here are some of the key provisions that go into effect within the next 90 days, 6 months, or year:

• SMALL BUSINESS TAX CREDITS— Tax credits of up to 35 percent of premiums will be immediately available to firms that choose to offer coverage. (Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)
• BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Completely closes the donut hole by 2020.

Some much needed investments in Primary Care:

• COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years. Effective beginning in fiscal year 2010.
• INCREASING NUMBER OF PRIMARY CARE DOCTORS—Provides new investment in training programs to increase the number of primary care doctors, nurses, and public health professionals. Effective beginning in fiscal year 2010.
• INCREASING REIMBURSEMENT FOR PRIMARY CARE SERVICES—Creates a 10% bonus for primary care services provided under medicare.
  

Some of the insurance regulatory reforms:

• ENDS RESCISSIONS—Bans health plans from dropping people from coverage when they get sick.
• NO DISCRIMINATON AGAINST CHILDREN WITH PRE‐EXISTING CONDITIONS—Prohibits health plans from denying coverage to children with pre‐existing conditions. Beginning in 2014, this prohibition would apply to all persons.
• BANS LIFETIME LIMITS ON COVERAGE—Prohibits health plans from placing lifetime caps on coverage.
• BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE—Tightly restricts new plans’ use of annual limits to ensure access to needed care.
• FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles.
• NEW, INDEPENDENT APPEALS PROCESS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan.
• ENSURING VALUE FOR PREMIUM PAYMENTS—Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders.
• IMMEDIATE HELP FOR THE UNINSURED UNTIL EXCHANGE IS AVAILABLE (INTERIM HIGH‐RISK POOL)— Provides immediate access to insurance for Americans who are uninsured because of a pre‐existing condition ‐ through a temporary high‐risk pool.
• EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE – Requires health plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice.
• PROHIBITING DISCRIMINATION BASED ON SALARY—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees.
  

sFurther, despite the disingenuous rhetoric of Rep Paul Ryan, this bill does not in fact cook the books. The funding is over ten years but the benefits are over six -- that sounds damning, but this graph shows that in fact the revenue collections and offsets rise very much in lockstep with the new expenditures over the next decade:

There's a little pre-paying of spending there, but it's small, and frankly it makes sense to book the revenues before you pay out the benefits, at least to some degree. Remember, as well, that the deficit savings are projected to increase in the subsequent years, too.

Overall, this is pretty good bang for the buck in the initial years. I'd still like to see the exchanges start up immediately, but the interim high-risk pools are a nice start (are they subsidized? I'm not sure). It will definitely give the Dems some good talking points leading up to November, and hopefully will start giving consumers some needed relief.

Fight for the Little Guys

I know that I want to say something, but I’m just not sure what nor how, so please bare with me.

Since being diagnosed with multiple sclerosis, I’ve learned more than a few things about how our insurance and health systems work. I’ve learned how it doesn’t work for the “little guy” - the self-employed, the individuals without access to protected group coverage, the folks living with chronic illness, those who truly cannot afford health insurance coverage but who fall right through the safety net programs.

According to the Centers for Disease Control and Prevention, chronic disease causes major limitations for 1 out of 10, or 25 million people, in the United States. Chronic diseases account for 70% of all deaths in the U.S., which is 1.7 million each year. These statistics from the home page of the CDC’s Chronic Disease Prevention and Health Promotion website.

When you are living with a chronic illness, access to health care services and providers is a basic necessary. In our country, obtaining access is expensive so health insurance coverage is also necessary. But if you have a chronic illness, then obtaining health insurance is a tricky matter. It’s not too bad if you are able to maintain employer-sponsored group health coverage because there are protections provided by law.

The regulations, however, differ from state to state regarding pre-existing health conditions. There is no basic standard of “no pre-existing condition coverage exclusions in the group market” which would simplify the rules. Simplification would eliminate so much wasted effort in trying to determine which rules apply to any given situation. Simplicity is good!!

But notice that I only mentioned employer-sponsored group health coverage. What about individual health coverage?

Well, individual health insurance coverage is a whole different ball game. The individual market does not have to play by the same rules as the group market. In fact, the individual market varies even more greatly from state-to-state. See Kaiser State Health Facts.

Do you recall when the Mental Health Parity Act was passed in 2008? Very exciting development in reforming health care. However, it only applied to group health coverage provided by employers, with more than 50 workers, who do not meet a cost exemption. Not for individual policies, not for Medicare, not for small businesses - only large groups. Again, not playing by the same rules but a move in the right direction.

So far these incremental moves are working to improve the health coverage of large groups, not the “little guy.” These changes do nothing to protect those of us exiled to the individual market and not eligible for assistance. I remember when Rudolph Guiliani was running for president. He advocated for millions of people to flood the individual market which would supposedly prompt insurance companies to create less expensive (meaning less comprehensive) policies to “meet individual needs and not government mandates.” I wanted to scream at the top of my lungs - No! NO! You do not want to have what I have. Stay safe and protected!

But as time has gone on in the past 2 years, I begin to have mixed feelings. I wish the best for others and hope that they may stay safe and covered. However, I also begin to wish that more people understood what being one of the “little guys” is like. Those who lose access to their employer-sponsored health coverage find it a cruel and expensive market out here.

With this in mind, I shouldn’t be surprised that the people around me who are fearful of the “health reform bill” are ones who are safe within their employer-provided, subsidized, tax-free, group health insurance coverage. And some of these same people believe that the safety net programs or charities will provide for those “truly in need.” So, next question is what does it mean to be “in need.” This is a tough one to answer, so I’m not even going to try right now.

But why are so many fearful of the health reform efforts being discussed publicly? Is it the fear of change? Is it the “I have mine, now you need to go get yours”? I was told before to “get a good job with benefits.” Well, lots of people are looking for jobs now, period. But what about those who live with chronic illness who may also be limited in their daily activities. Could each of them find a job with good benefits and maintain employment?

Before being diagnosed with multiple sclerosis, I felt safe in having had the foresight to obtain health coverage when I was healthy. I even obtained the highest level of coverage available to me as a self-employed freelance musician. I was proud to be acting as a responsible grown-up.

After being diagnosed and prescribed Copaxone (which costs about $30,000 each year), a friend at the swimming pool asked me, “will your insurance cover it?” See, she has a son who has MS and was well aware of the disease and its treatment options. I innocently replied, “I guess we’ll find out.” Obviously, I thought that the answer was a given. Copaxone was listed on the formulary and my insurance had drug coverage. Well, I learned that it wasn’t that simple.

After struggling with the insurance company and basically begging the assistance program for the help I needed, I learned that nothing is truly that simple. I fell right through the big gaping holes in the safety net programs. Not just one, but many of them. Even my parents who are secure in their FEHBP coverage have had their eyes opened to the problems with our health insurance industry and the lack of federal laws to regulate the ENTIRE system, not just portions of it.

So why are others so fearful of reform? and fearful of having the government establish a level playing field for all? I’m somewhat baffled by this. We have such a mishmash jigsaw puzzle of a system, what is so wrong with creating a system which would truly promote choice and competition?

So here’s what I want to say today - I’m one of the “little guys” and I need the help!!

Gratitude Friday and Health Care Questions

There are always at least two ways to look at any situation. After a really tough summer with my MS, I am thankful that I'm ready to get back to work, ie. focusing on my health and wellbeing. I will be starting back to physical therapy soon and am doubly thankful that my insurance does pay for that treatment.

I like that photo above - a horse and zebra mix. A dichotomy in one creature.

Life is full of dichotomies which coexist peacefully. Today, I'd like to do something different. I'd like to ask you to answer a few questions. The result of which will show the differing opinions and experiences of the members of our community.

Here are the questions:

1. How many doctors do you have and how often do you see each one in a year?

2. Do you have health insurance? If so, how have you obtained it? ie. through your employer, through a spouse's employer, on your own independently, through retirement benefits or through Medicare or Medicaid?

3. How much does your coverage cost? How much are the premiums? What is your deductible? How much are your copays and/or coinsurance? Do you have prescription coverage?

4. What are the top three aspects of your health care and health insurance which you APPRECIATE the most?

5. What are the top three aspects of your health care and health insurance which you DISLIKE the most?

6. What are your greatest CONCERNS when it comes to changes in how health care is provided (ie. delivered, financed, regulated)?

7. What are your greatest HOPES when it comes to changes in how health care is provided?

Bonus questions:

Do you know how many legislative health reform proposals have been introduced in Congress this session (in the US only)? Have you read any of the proposals? If you were "ruler of the world" how would you change things?

Please keep the conversation civil. No talk of "death panels" or "angry mobs."

I thank you in advance for you responses.

Please go to HealthCentral to comment (even if anonymously):

Gratitude Friday and Health Care

Getting Squeezed

This week I received the annual note from Carefirst BCBS, my insurance company, informing me what my new health insurance premium rate will be for the upcoming 12 months. Of course, I expected that it would go up, no matter how I wished it wouldn't.

What I didn't expect was HOW MUCH it was going up!! 31% increase

OK, so it's not the first time the rate has gone up substantially -
In 2003, it was 22.2%. In 2004, 18.2%. In 2007, 19.9%. In 2008, 18.8%.
(see graph below)

But COME ON. Enough is enough. another 31%?

For insurance which doesn't pay for my MS medications, I will be paying $5172?

That's just for me, no one else, and is not subsidized by any employer since I am self-employed. And unlike most folks who have employer-sponsored health insurance, I will be paying Social Security, FICA, etc taxes on that $5172.

Why doesn't Carefirst cover my main MS medication, Copaxone?

• Because the drug benefit for individual policies is capped at $1500 annually.

How do I get Copaxone if insurance doesn't cover it?

• I have to qualify for assistance from NORD which administers the PAP.

How do I do that?

• I must earn less than 200% Federal Poverty Level (FPL) and can't have significant amounts of money in savings.

How much is 200% FPL?

• This year (2009), it is an Adjusted Gross Income (AGI) of $21,660.

For more on this story, see The Value of Money or Value of Health: What Do You See?

Now, to be fair, the $5172 in insurance premiums will not be 24% of my 'total income.'

Since I'm self-employed, I get to deduct the amount spent on health insurance premiums before income taxes are calculated. So it's a minimum of 19.3%, after Social Security/FICA tax is accounted for and before the AGI is calculated.

But, please tell me. Who can afford to spend 19-24% of the highest level of income they can afford (or are allowed) to earn for health insurance premiums?

And let's just say that for 2008 I did earn considerably less than 200%. In fact, $5172 really would be closer to, if not more than, 25% of total income.

According to proposed health care reform legislation, affordable premium rates for someone with my income level would be closer to 5% of income AND I would very likely have coverage for my medical needs, including pharmaceuticals.

Update: Now it looks like the Public Opinion just might get dropped during negotiations in Congress. Sigh.