President Obama’s speech Wednesday night clarified what he will, and won’t, accept from Congress. It also was politically artful, mollifying the liberal Democrats while borrowing from Republican positions in an effort to give just enough to each to keep the process moving.
My main takeaway was this – for the first time, substantial attention was paid to cost, with a good chunk of the speech focused on reducing spending due to unnecessary care, excessive Medicare Advantage subsidies, and squeezing out administrative cost.
This is the speech that should have started the health reform campaign.
Instead we’re far into the legislative process, and many, if not most, Americans are uneducated about and unaware of the key issues reform should address. Example – I had dinner Friday night with several well-educated people in Chicago, one of whom is a nurse anesthetist married to an anesthesiologist. She railed against the reform bills’ negative impact on physicians, but could not point to any specific issues or clauses or reimbursement changes in any of the bills currently before Congress. She complained vociferously about the cost of medical malpractice insurance, stating that this is not a problem in any country but ours. The others listened, as to them, she is deeply involved in the industry and therefore an ‘expert’.
This is why the chances for health reform are dim and fading. The Democrats ceded the field of public debate to opponents of reform who successfully focused the public’s attention on secondary issues such as tort reform while avoiding any discussion of cost (which would mean lower revenues for reform opponents). Now the President is paying catch-up, trying to educate the American people about the problems, cost drivers, and inefficiencies in health care. This education will not happen overnight. Wednesday night he set the stage, raised a number of good points, and was generally accurate in describing the health care system’s cost drivers.
It would have been the perfect speech except it wasn’t in May.
I’ll temper my comments with the observation that then-Senator Obama was counted out last August, appearing to stumble while his opponents soared, only to soundly trounce Senator McCain three months later, winning several states that had historically been solidly Republican. He also defeated the Clintons to win the Democratic candidacy, an accomplishment that cannot be overstated.
Can the President get reform done? Possibly. But not probably.

This is it – President Obama’s speech tonight will be the single most important health reform event this year. Here are the key things to watch for.
The reactions of Sens Grassley, Enzi, and Snowe are more important than the content. More important, even, than any Presidential pronouncements about public options and tort reform. Without bipartisan support, however thin, nothing gets done, and these are the three keys to that elusive bipartisan stamp.
Cost control – to date the Dems in the House have passed several bills out of Committee greatly expanding coverage at huge cost. Health reform without cost control is not possible nor should it be. The President must address cost, and do so directly.
Lines in the sand – I don’t expect there will be any, especially any referring to a public plan option from day one. But there will be ‘requirements’ for coverage, perhaps timeframes, and possibly a trigger for implementing a public option if specific criteria aren’t met by the private insurance market. How tight these are will go a long way to revealing how far the President will go to get reform passed.
Tort reform – the President’s treatment of this topic will be highly instructive. If he signals a willingness to include tort reform in a health reform bill, that will show a) he’s open to make big concessions to get reform done; and b) opponents that the stakes are raised. Getting tort reform done is a high priority for many in the industry, and they will likely be willing to compromise on other points if they get what they perceive to be meaningful reform.
What to ignore
The slamming by opponents and hyperbowling (a term used to describe advocates hurling positive adjectives at any microphone) immediately after the speech. Turn off the coverage and get back to your fantasy football picks – it will be more productive and less stressful.

President Obama’s speech to a joint session of Congress tomorrow night looks like the last best hope for health reform in 2009. Despite all the protestations about ‘ObamaCare’, the reality is the President has been remarkably silent on health reform specifics, preferring to let Congress work out the details, as long as they meet his goals of coverage and ‘budget neutrality’.
This looks to be the result of a careful analysis of ‘what went wrong’ with the Clinton health care reform effort, an effort blown apart by too many details that elicited devastating criticism. While some may accuse the President of fighting the last war, others note that Obama, as a relative newcomer to the Capital, understands that many in Congress, and particularly the Senate, have long experience with health care and much pride in that experience, and would resent what they might see as a heavy handed attempt by the new guy to dominate an issue that they view as their own.
Regardless, we’re now at the point where the speech, and moderate Democrats’ and Republicans’ reactions to that speech, may be the turning point in the reform effort.
Obama has largely kept his powder dry, avoiding ‘deal-breakers’, lines in the sand, and ‘non-negotiables’, and the same can be said for the Republican Senators key to a true ‘bipartisan’ deal – notably Enzi and Grassley. (Snowe is a different story; she’s the one hope for Democrats seeking to shove something thru with some form of a public option.) Despite the escalating rhetoric on the part of the two Senators, they have – so far – pretty much avoided had line positions.
This modicum of restraint on the part of the President, Enzi and Grassley, is the key to coming up with something that a) can be passed; b) is more than just a tweaking around the margins; and c) promises to control costs while expanding coverage.
A solid set of principles that would form the basis for agreement has been developed by Bob Laszewski, and are the subject of a measured piece by Brian Klepper and David Kibbe. Klepper and Kibbe suggest the following:

* Bulletproof Health Care Security. This is the idea that everyone would have significantly improved access to care, that the employer-sponsored system would remain available for those who like it, and that Congress would be required to use the same system that they pass for the rest of us.
* Medical Malpractice Reform. The Republicans have the Democrats where they want them on this one. There is no good reason why our current Med Mal system, as capricious and ineffectual as it has been, has not been revised with expert systems, except that the trial lawyers, in exchange for hefty financial support, have received protection from the Democrats. It’s time to fix this problem that pervades our health care provider community.
* Paying for It. This is acknowledging that subsidies will be required for those who can’t afford health care at its current cost level, and that there are ways to structure the new cost that are more sensible. As Bob points out, the nearly forgotten Wyden-Bennett bill would be cost neutral in its second year.
* Tough Cost Containment. As we said above, this has been the Congressional Democrats’ proposals’ most glaring and conflicted flaw. It is an area that, with a focus on primary care, paying for results instead of piecework, and cost/quality transparency, could dramatically drive down cost while improving quality, rightsizing our health system and going a long way toward ameliorating the most pernicious drag on our larger economy. Bob tackles cost control most effectively in his Health Care Affordability Model, a plan that would use tax incentives to encourage the industry to focus on driving out waste.

There are a couple huge political plusses for the Republicans in the ‘Four Points’.
First, to date the Dem’s proposals have been woefully short on cost containment, and woefully long on unfunded entitlements. By getting tough on costs, the GOP may be able to find one issue where it has a fresh, new perspective – something the party desperately needs. Sure, they’d infuriate a big donor base, but that would be an acceptable price to pay for a party that needs something to build on for next year’s mid-term elections.
Second, Enzi, Grassley et al would earn big points from the medical provider and manufacturing industry by attacking Med Mal. A successful ‘solution’ to what is perceived to be a big cost driver (although the data don’t support that perception) would play very well with their base, and take some of the sting out of the cost containment provisions.
This is not to make light of the significance of the issue for the Dems as well – passing health reform is a must-do. There’s a lot of political capital at stake so passing it will boost the party’s credentials while failing to do so will cut deeply into the public’s view of the Democrats.
What does this mean for you?
By September 30 we’ll know if reform is still alive. If Grassley and Enzi aren’t sounding strident and protesting ‘heavyhanded Democrats’, we may still get there.

Last week’s post about what will happen if we don’t have health reform got me (and a couple others) thinking about the downstream impact – on employers, manufacturers, taxpayers.
Before we delve into the impacts, a bit of clarification.
My statement that a family policy would cost $30,000 in 2016 was based on the latest info from two large consulting firms about commercial health insurance premiums – rates are going up more than ten percent next year. And it is highly likely they will continue to accelerate at or near the ten percent number. Two commenters noted that just because something happened in the past does not mean it will continue into the future – I’d respectfully note that while that is true in the abstract, in the concrete world of health insurance, there’s a very high likelihood that costs will indeed go up ten percent – or more – per year for the foreseeable future absent meaningful cost reform.
The AON survey reports trend rates ranged from 16.0% and 18.2% for HMo, PPO, Indemnity plans in 2002, 15.7% – 17.2% in 2003, 14.1% – 15.3% in 04, 12.7% (CDHP) to 14.6% in 05, 11.9% – 14.4% in 2006, 10.7% – 12.7% in 2007, and 10.5 – 12.4% in 2008.
The past is a pretty good predictor of the future; over the last eight years cost have consistently increased more than ten percent each year, with most increases well above that level. Whether we are at the bottom of the cycle or cost inflation rates will continue to decrease is unclear, but what is clear is that the inflation rate will head back up at some point in the next few years.
Back to the real world impact.

• If nothing changes, the share of the nation’s budget paid by the government will be greater than that paid thru private insurers.
• 178,000 small business jobs will be lost by 2018 as a result of health care costs
• If employee contributions stay at their current level (about 30% of premiums), workers will be paying $9000 per year, or $750 per month, towards their health coverage – not including deductible, copays, coinsurance, and services not covered
• General Motors’ health insurance will add about $3000 to the cost of each vehicle – if it is still in business>li>In my hometown of Madison, Conn., Town employee health insurance costs are paid for with property taxes; without reform the amount of tax revenue needed to pay those bills will double by 2016, forcing tax increases and/or significant service cuts
• More Americans will have to rely on the kindness of others for their health care
• Because 65 million of us will be without health insurance

Unlike the distortions, misrepresentations, and outright lies being spread by McCaughey, Limbaugh, Palin et al, this is the real deal. So fight against reform if you wish, but don’t complain later when you can’t afford insurance, your employer can’t afford insurance, your taxes are going up to pay for teachers’ benefits, and our economy is sinking under the weight of health care costs.
(Note – as I said Friday, health ‘reform’ must include cost control, something neither party has bothered to meaningfully address)

It’s quite clear the public plan option is not going to be part of any health reform bill, if any health reform bill is passed.
This despite the announcement yesterday that sixty progressive/Democrat members of Congress signed a document that they would not support a reform bill that does not include a public plan option. While I admire their willingness to take a stand, I don’t believe that they will follow through.
THe good folks at the Campaign for America’s Future invited me to participate in a call yesterday with Dr. Jacob Hacker, the brains behind the public plan option, as well as two Congressmen, Rep. Raul Grijalva and Keith Ellison. The gentlemen waxed eloquent about the progressive caucus’ commitment to the public plan option, and all the reporters who got to ask questions focused on the political issues surrounding their position.
I didn’t get to ask the ‘other’ question, which was in three parts; “How will this save money, and how will you convince providers to sign up, and how will it prevent cost shifting to private plans?”
Dr. Hacker addressed these questions in a monograph published by CAF; providers would be automatically signed up but could opt out; reimbursement would be set at 5% above Medicare; and cost-shifting is overblown.
I don’t agree with Dr Hacker that most providers would join (why would they join a plan with no members at reimbursement much less than they are currently getting to serve their current patients?) or that cost-shifting is overblown – I see too much of this every day. I also don’t see how a public plan would control the single biggest driver of health cost – utilization.
But it doesn’t really matter if he’s right or I’m right or we’re both wrong – what matters is the political reality is there aren’t the votes in the Senate to pass a plan with a public option.
The continued political brawl over the public option is pointless on at least two levels – it is clear there is not enough support for the option to include it in a bill that will pass the House and Senate, and if health reform legislation is written intelligently, the public option is unnecessary. Moreover, I seriously doubt the progressives will fall on their collective swords and vote ‘No’ on a comprehensive health reform bill if it doesn’t include a public plan option.
My sense all along has been the public option is a stalking horse, one that the President and a few Democrats let out of the stable to create a little excitement, rile up the opposition, and distract attention from other provisions that are more important and meaningful, like insurance reform, mandated universal coverage, and comparative effectiveness research.
Boy were they successful. Once out of the stable, the horse took off bucking and snorting, and kicked up enough of a ruckus to perhaps kill the whole reform process.

The scaremongers have apparently succeeded in forcing Senate Democrats to remove end of life planning from their health reform plans. This despite the original provision was introduced by a Republican (Johnny Isakson of Georgia) support of the measure by none other than conservative icon Newt Gingrich (at least he supported it until a few weeks ago…), a new study that demonstrates the importance of end of life planning, and the bill itself, which does NOT include mandatory ‘advance care planning’.
(Section 1233 of America’s Affordable Health Choices Act of 2009 amends the Social Security Act to ensure that advance care planning will be covered if a patient requests it from a qualified care provider [America’s Affordable Health Choices Act, Sec. 1233]. Media Matters notes “According to an analysis of the bill produced by the three relevant House committees, the section “[p]rovides coverage for consultation between enrollees and practitioners to discuss orders for life-sustaining treatment. Instructs CMS to modify ‘Medicare & You’ handbook to incorporate information on end-of-life planning resources and to incorporate measures on advance care planning into the physician’s quality reporting initiative.” [waysandmeans.house.gov, accessed 7/29/09])
The reality is a relatively innocuous provision that had broad bipartisan support and was widely recognized as appropriate and helpful by the medical community has been used by opponents of health reform to scare the bejesus out of enough Americans to force its removal from the (future) Senate Bill.
And if you think the battle is over, you’re sadly mistaken.
I don’t know what seemingly mundane the next battle will be over, but if reform opponents can use advance life care planning as a cudgel to beat the heck out of the Democrats, than no provision is safe.
The Dems have all but lost the reform battle; polls are not favorable, opponents have created fear and concern among independents and moderates, and the President has been unable (to date) to use his formidable communicative powers and infrastructure to regain the momentum.
Unless President Obama and the Democrats get their act together, reform’s chances are fading like an iceberg in a heat wave.

There are definitely more than ten, but here’s my list.
10. A federal death panel will decide who gets care and who gets ‘suicide-d’. This has been debunked almost as many times as it’s been ‘bunked’, Section 1233 of America’s Affordable Health Choices Act of 2009 amends the Social Security Act to ensure that advance care planning will be covered if a patient requests it from a qualified care provider [America’s Affordable Health Choices Act, Sec. 1233]. According to an analysis of the bill produced by the three relevant House committees, the section “[p]rovides coverage for consultation between enrollees and practitioners to discuss orders for life-sustaining treatment. Instructs CMS to modify ‘Medicare & You’ handbook to incorporate information on end-of-life planning resources and to incorporate measures on advance care planning into the physician’s quality reporting initiative.” (Media Matters)
9. Illegal aliens will get free coverage. Nope, not true. In fact, none of the plans currently before Congress would allow the federal government to provide health coverage for illegal immigrants. The federal government does not currently provide coverage for illegal immigrants.
8. It’s deficit neutral. President Obama has repeatedly claimed the current health care reform initiative will be paid for by savings, increased taxes on wealthier Americans, and reductions in Medicare Advantage and other payments. I doubt it. Providing coverage to tens of millions of folks who don’t have it now will increase utilization – just like it did for Part D – and we can probably expect prices to go up too.
7. Health reform will lead to rationing. Again, I guess it depends on your definition of ‘rationing’. If ‘rationing’ will reduce the amount of unnecessary and probably hurtful care, that’s a great result. According to the Dartmouth Atlas, about a third of the health care delivered to Americans is not necessary and wasteful. I’m fine with eliminating that care – even if that means I can’t get an MRI on my twisted ankle. That’s not rationing, that’s good medicine. Unfortunately, I don’t see that happening anytime soon. And therein lies the problem with the ‘deficit neutral’ argument – more coverage will mean more services which will cost more money, driving up the nation’s health care cost.
6. The free market which can solve the problem without government intervention. I’d agree (and have stated before) that the private insurance market could fix our health insurance problem, but there has to be a market first. The reality today is that almost every market is already dominated by a very few health plans, so much so that in most markets, there really is very little market competition amongst health plans. Until and unless we have open competition, we won’t have choice.
5. This is socialism. Well, I guess it depends on your definition of ‘socialism’. According to generally accepted definitions, socialized medicine is when the government employs the doctors and owns the hospitals and provides the insurance. None of the bills under consideration are anywhere close to that -which, BTW, exists in a relatively few countries like the UK and Cuba. In the proposed system, private insurers would continue to provide insurance to most non-seniors, Medicare would continue, and providers would remain independent.
4. My tax dollars would be used for abortions. Yes and no. Federal dollars for abortions are currently quite restricted, and would continue to be. Coverage for abortion services would remain only for rape, incest and to protect the mother’s life.
3. We should just can all the private insurers and go to single payer, which will save lots of money in administrative expense. Not true. Private insurers have to account for and report future liabilities; the government doesn’t. The ultimate liability for Medicare and Medicaid is in the tens of trillions of dollars. Moreover, the admin expense argument is unfair as the Medicare population is markedly different from the demographic served by private insurers. First, there’s only one enrollment per lifetime. Second, there are minimal marketing/advertising expenses. Third, there are no premium taxes or other costs of compliance. No, while admin expenses would be lower, the huge savings touted by single payer advocates result from an unfair analysis.
2. A public plan would crush private insurers and we’d all end up covered by the public plan. Not even close to the truth. Some continue to complain private health plans will not be able to compete with a public option as the public plan will just dictate pricing to providers, and public plans wouldn’t have the capital and financial stability requirements forced on private plans. They’re half right. Re the capital requirements, they’ve got a valid argument. As we know all too well with Medicare and Medicaid, the Feds (and we taxpayers) have an ultimate unfunded liability in excess of $22 trillion, but that figure doesn’t show up on any formal financial statements.
But when they complain about pricing, that’s a red herring – for two reasons.
First, physicians don’t have to accept Medicare or Medicaid, and wouldn’t have to agree to any ‘public option’ pricing. In fact many docs don’t accept Medicare today. As participants in the free market, they are able to opt out if they feel the compensation is too low – and many do.
The other factor is just as simple – pricing is but one component of the health cost equation. The others are utilization and frequency. ‘Utilization’ is the number of a specific type of services used by a patient, while ‘Frequency’ is the percentage/number of patients that use that type of service. And Medicare has not shown any ability to address either of these two factors.
1. And the top misperception about health reform – it will mean a bureaucrat will determine my health care, not me and my doctor. Uhhh, what do you think happens now?

Pull out your health insurance card, and turn it over. See the phone numbers on the back? Those connect you (first to voice mail hell), then eventually, if you’re lucky and very persistent, to a ‘bureaucrat’, albeit one employed by your health insurer. They might even be located offshore …

Jonathan Cohn writing at ‘The New Republic’ has summarized what’s happening with health reform better than I could. Here’s an excerpt:
“Exhibit number one is the treatment of Eziekel Emanuel, the distinguished oncologist and bioethicist who is working on health reform at the Office of Management and Budget. In the course of his writings, which span academia and popular publications, he has argued forcefully and clearly against physician-assisted suicide. Yet somehow Emanuel finds himself accused of–wait for it–advocating physician assisted suicide…The attack on Emanuel is part of a broader offensive–an effort to persuade anxious Americans that health reformers will harm people who are seriously ill or who have disabilities…Every year, millions of families struggle to get affordable medical care for themselves or their loved ones–and end up in financial ruin, going without medical care, or some combination of the two. Many of these cases involve diseases like cerebral palsy or Parkinson’s–or other conditions that require ongoing, expensive care.
Insurance companies try their best to avoid taking on these people. Apply for an individual policy with one of these pre-existing conditions and an insurer will reject you if it can. If it can’t–if, say, you’re lucky enough to get coverage through an employer–you may well find the insurance doesn’t cover what you need.
Changing that isn’t merely a by-product of reform. It’s the whole point of reform. The plan Obama and his allies support would make coverage available to everybody regardless of pre-existing medical conditions. It would require insurers to cover a broad range of medical services. And it would police insurers to make sure they didn’t try to get around those requirements.”
Bob Laszewski has a similar perspective.
“Sarah Palin want-to-be Betsy McCaughey, who had her last 15 minutes of fame during the Clinton health care debate, claims Dr. Emanuel endorses age discrimination for health care services–basically saying he wants to pull grandma’s plug.
NICE actually makes the British system’s tough decisions so many worry might have to be made here. For example, last year NICE issued guidance rejecting kidney cancer drugs Sutent (sunitinib), Avastin (bevacizumab), Nexavar (sorafenib) and Torisel (temsirolimus). This leaves patients with only one treatment option – interferon. The reason is these drugs only extended the life of the patient a very few months but they cost about $200,000 to keep a patient alive that long.
Dr. Emanuel is one of the most widely respected health care ethicists in the country. The issues McCaughey is using were quoted out of context and had to do with one of the things Dr. Emanuel gets to think about at the National Institutes of Health–what to do when you don’t have enough organ donors for those who want organs.”
The question that opponents of reform are ignoring is this: “what happens to me and my family if Iose my health insurance? Am I confident that I will get the health care coverage I need at a price I can afford? And when prices double in ten years, will that still be the case?”
Our current health care system is unsustainable. Opponents of reform who do nothing but lie and have no real solutions will have no one to blame but themselves if reform fails and they can’t get insurance or care.

Yesterday we examined the potential impact on insurers and insureds of a failure to pass meaningful comprehensive health reform . Today we’ll look at the effect on providers.
Again, we’ll leave aside the possibility of individual bills addressing physician compensation under Medicare, a superMedPAC and other potential measures.
As health care costs increase, the number of employers who can afford coverage drops, as does the percentage of their workers willing to pay their share of the premium. And without meaningful reform that includes cost controls, there is zero evidence that costs will moderate on their own. While the cost cycle will persist, without structural change in the form of changed incentives for payers and revamped reimbursement by Medicare we’re stuck with the same underlying trend of a couple points higher than overall inflation.
The latest data indicate this is already happening, as the largest health plans lost over four hundred thousand commercial members in total in the first quarter.
We’re looking at fewer working families with insurance, but there’s another problem – as employers change to high deductible plans, or increase the deductibles on current plans, employees will have to come up with more cash to pay for their care before their insurance kicks in. Fact is, almost one-fifth of Health Savings Accounts don’t have any funds in them, and most aren’t fully funded (the average account balance was about $950 for individual accounts and $1500 for family as of Q3 2008). Moreover, that only counts the folks who are enrolled in HSA-type plans who’ve opened accounts; according to a GAO study, in 2007 almost half of HSA-eligible plan enrollees hadn’t opened an account.
The net? More patients without coverage, and a sizable chunk of those with ‘coverage’ don’t have funds to pay their deductibles. The result? More indigent care, more unpaid bills, and more trips to the ER instead of primary care doc visits, trips that won’t be compensated and will therefore result in more losses for hospitals and cost-shifting to the shrinking population of commercial insured patients.
Specialties that will be particularly hard hit include orthopedics, ophthalmology, dermatology, ob/gyn, neurology, physical therapy and neurosurgery. With many of their patients presenting with non-emergent conditions, these specialists will likely see a decline in patients as those without coverage put off care – that aching knee, slightly blurry vision, skin blotch or loss of sensation will be ignored as much as possible as long as possible. Ob/gyns will see an increase in indigent care, and a potentially considerable growth in patients covered by Medicaid (a notoriously poor payer in many states).
The consolidation in the payer industry (noted yesterday) will shift more bargaining power to healthplans, especially for physician contracts. Hospitals are a little better off, as many have gotten pretty good at negotiating with insurers and their proxies. But for those providers in markets with two or one dominant payer, rate negotiations will become increasingly one-sided.

We know that much of the town hall opposition has been funded by right-wing advocacy groups. What we don’t know is what will happen if they are successful in stopping Congress’ efforts to pass and the President’s to sign a comprehensive health care reform bill.
I’ll leave aside the potential impact of bills addressing a ‘superMedPAC’, changes to Medicare physician reimbursement, and the possibility that HHS will get a better deal from big pharma. What will our country’s health system look like in five years if there isn’t reform?
Today we’ll look at insurers and families, tomorrow providers and the ‘macro’ impact.
Impact on insurers
Without reform of the insurance underwriting and rating laws, insurers will seek to be even more selective about the policies they write. That’s already starting to happen, and is a major reason the larger health plans are losing members this year for the first time in recent history. They just don’t want the ‘risk’ that someone will have a claim. Healthplans will also continue to ‘churn’ their books – to try to dump policies that have been in place for more than three years, as that is about when claims start to pile up.
Can’t blame them, as many are for-profit and therefore more committed to shareholder returns than patient care. That is not a value statement – it is a statement of fact.
The number of viable healthplans will continue to shrink. As a mature industry, the healthplan business has been steadily consolidating – if anything that will accelerate. And no, the free market will not increase ‘choice’; we already have a free market for commercial plans (and Medicare Advantage and Part D) and in most areas there are at most two plans to choose from.
Smaller healthplans will find it increasingly hard to compete, as the big plans get ever-better discounts from providers, who have to make up the lost revenue by cost-shifting to the smaller plans with less clout. As their costs go up, so will their rates, until they either wither away or get bought out by the big plans.
PPO plans will get ‘nichier and nichier’. Their higher medical costs will push members towards HMO-type plans, making it harder for employers with widely-spread workers to get affordable coverage unless they buy insurance from one of the big plans that operates in all the areas the employer has bodies. Inevitably, some workers will be left with poor coverage…
Impact on individuals and families
Bureaucrats at insurance companies will still be making decisions about what doctors you can see and how much they’ll pay and what they’ll cover and what they won’t. You’ll have to ask permission for services, and hope and pray they get paid. Those same bureaucrats will tell you they’re interested in keeping you healthy, but that’s only till they can churn you out of their book.
There will continue to be a hodgepodge of state-specific insurance mandates, rules, regulations, and enforcement mechanisms, as well as benefit designs and limitations. I’d note that under some of the reform bills under consideration, states will maintain a very significant regulatory role, but the benefit design and other ‘customer-facing’ issues should be simplified.
But the big problem is this – it will get harder and harder for individuals and employers to get insurance coverage.
Here’s one all-too-common scenario. The breadwinner loses her/his job, and with it health insurance coverage. They find a new job, but that company doesn’t offer benefits as they are too expensive. So, Ms/Mr Breadwinner, responsible person that s/he is, tries to buy an individual policy. There are several insurers that write those policies, so the applications go in – followed by requests for medical records, documents, and attestations signed by their physicians. Oops, one of the family has a mild case of asthma, and dad takes cholesterol medication, and mom saw a counselor a few years ago after her dad died.
Three insurers decline to offer a proposal, and the one that does will exclude any cardiovascular coverage for dad, any pulmonary issues for junior, and mom won’t be covered for any psychiatric or anxiety or related issues. And, oh, the policy is 50% more expensive than the original quote. Leaving Mr/Ms Breadwinner to decide if they want to come up with $22,000 a year for less-than-full coverage and their HSA deductible (in 2009 dollars)…
Unfortunately there isn’t any governmental assistance, so the Breadwinners, who make $75k a year, are looking at spending almost a third of their gross income on health insurance – insurance that doesn’t cover their most likely health problems.
Think this is hyperbole? You’re wrong. This is happening every day in every community, and if health reform doesn’t happen, it is going to happen more and more often.
Unlike the right-wing fear death panels, this is reality.