Improve Prevention by Paying for What's Important

In this commentary Dr. Bazemore and I discuss 3 ways in which health reform could improve the delivery of preventive care. We need to align preventive care with the USPSTF recommendations, and start paying for preventive coordination. The current health reform bill offers some ways to do this, but we need to experiment with more ways, so that older Americans can prevent disease and live a more fulfilling life.

JAMA -- Improving the Delivery of Preventive Services to Medicare Beneficiaries, December 23/30, 2009, Lesser and Bazemore 302 (24): 2699

We Have 60!

While this bill isn't perfect, it will do a lot of good things to help a lot of people struggling with lack of health insurance. Here are the highlights of what should pass this week. What's not included in this summary is that the nonpartisan Congressional Budget Office states that the bill will reduce the deficit by $132 billion over 10 years.

Manager’s Amendment to the Patient Protection and Affordable Care Act

Providing More Competition & Affordable Choices for Americans

The Manager’s Amendment to the Patient Protection and Affordable Care Act builds upon the strong bill we already have. It demands greater accountability from health insurance companies while creating more choice and competition for consumers. It implements new programs to further rein in health costs and makes health insurance policies more affordable; and it improves access to quality, affordable health care for children and vulnerable populations.

Tougher Accountability Policies for Health Insurance Companies

• Stronger medical loss ratios. Health insurers will be required to spend more of their premium revenues on clinical services and quality activities, with less going to administrative costs and profits – or else pay rebates to policyholders. These stricter limits will continue even after the Exchanges begin in 2011, and apply to all plans, including grandfathered plans.
• Accountability for excessive rate increases. A health insurer’s participation in the Exchanges will depend on its performance. Insurers that jack up their premiums before the Exchanges begin will be excluded – a powerful incentive to keep premiums affordable.
• Immediate ban on pre-existing condition exclusions for children. Health insurers will be immediately prohibited from excluding coverage of pre-existing conditions for children.
• Patient protections. Health insurers will have to abide by a set of patient protections that, for example, protect choice of doctors and ensure access to emergency care.
• Ensuring access to needed care. The use of annual limits on benefits will be tightly restricted to ensure access to needed care immediately, and will be prohibited completely beginning in 2014.
• Guaranteed opportunity to appeal coverage denials. All health insurers will be required to implement an internal appeals process for coverage denials, and states will ensure the availability of an external appeals process that is independent and holds insurance companies accountable.

Stronger Policies to Make Health Care Affordable

• Innovation. Medicare will be able to test new models and, if successful, implement them via a stronger Innovation Center, Independent Payment Advisory Board, and other authorities.
• Transparency. New requirements will ensure that insurers and health care providers report on their performance, empowering patients to make the best possible decisions.
• Small businesses. A package of improvements include starting the health insurance tax credit in 2010, expanding eligibility for the credit, and improving the purchasing power of small businesses.

More Health Insurance Choices

• Multi-state option. Health insurance carriers will offer plans under the supervision of the Office of Personnel Management, the same entity that oversees health plans for Members of Congress. At least one plan must be non-profit, and the plans will be available nationwide. This will promote competition and choice.
• Free choice vouchers. Workers who qualify for an affordability exemption to the individual responsibility policy but do not qualify for tax credits can take their employer contribution and join an exchange plan.

Improved Access to Quality Health Care for Seniors, Children, and Vulnerable Populations

• Quality of care in Medicare. Seniors will benefit when additional health care providers are reimbursed by Medicare for the quality of care they deliver, not the quantity of services they provide.
• Children’s health. Support will be extended for the Children’s Health Insurance Program and the adoption tax credit. Foster care children aging out of Medicaid will be able to retain its comprehensive coverage.
• Community Health Centers. A substantial investment in Community Health Centers will provide funding to expand access to health care in communities where it is most needed
• Rural and underserved communities. Access will be expanded through funding for rural health care providers and training programs for physician and other types of health care providers.
• Vulnerable populations. A range of new programs will tackle diseases such as cancer, diabetes, and children’s congenital heart disease, will improve the Indian Health System, and will provide support for pregnant teens and victims of domestic violence.

Identifying Alternatives to Litigation

• Testing new models. States will be eligible for grants to test alternatives to civil tort litigation that emphasize patient safety, disclosure of health care errors, and early resolution of disputes, with a provision for patients to opt-out of these alternatives at any time. Alternatives will be evaluated to determine their effectiveness.

Current State of Health Bills

From Moveon.org :

Here's where we are:

The House of Representatives passed their bill last month. The Senate is aiming to pass its version before Christmas.

Overall, both pieces of legislation would do four major things:

• Create a "Health Insurance Exchange." The bills create a one-stop marketplace where people can choose from various insurance plans, including the public option. The details aren't set yet, but initially the Exchange would likely be open to the self-employed, people without insurance at work, and small businesses.¹ The key with the Exchange is that it brings "the bargaining power and scale that's generally accessible only to large employers" to individuals—and with that, lower costs and better options.²

• Provide insurance to over 30 million more people. The House bill would expand coverage to 36 million people by 2019. The Senate bill extends coverage to 31 million.³

• Outlaw discrimination based on pre-existing conditions and gender. Insurance companies will have to stop denying coverage to people with "pre-existing conditions." And they won't be allowed to charge women more than men for the same coverage.⁴
  


• Eliminate coverage limits and price-gouging. The bills differ on some details, but in general would place limits on how much people have to pay for health care beyond their premiums. They both cap out-of-pocket costs and ban insurance companies from setting limits on how much health care they'll cover for a person each year.⁵

Of course, the devil is in the details, and much in these bills still needs work.

Here's what still needs to be fixed:

• Both bills leave millions uninsured. The House bill leaves 18 million without insurance in 2019; the Senate bill, 24 million. Neither comes close to the vision for universal coverage so many of us fought for for years. We'll all need to fight to continue to expand coverage in the bills this year, and in the years to come.⁶

• The Senate public option is weak, and conservatives are pushing to make it weaker. The public option is a core piece of reform that will create real accountability and competition for private insurance—and that's why it's at the center of such a huge fight. While the House bill creates a national public option, the Senate lets states opt out, denying their residents access to it. Plus, conservatives are working to weaken it even more. We're all going to have to fight hard for the strongest version possible.⁷

• Many reforms don't start quickly enough. While some pieces of reform go into effect right away, the larger structural changes are not scheduled to go into effect until 2013 (House bill) or 2014 (Senate bill). This includes the Exchange, the public option, and subsidies—the major ways coverage will be expanded.⁸

• Required insurance could still be too expensive for many. Both bills require virtually all Americans to have insurance. But the caps on how much we're expected to pay are way too high, and the subsidies are way too low. Many progressives are working to fix this, but it's going to be a significant fight.⁹
  

• Reproductive rights are severely restricted in the House bill. An egregious anti-choice amendment in the bill virtually prohibits anyone purchasing insurance in the Exchange from buying a plan that covers abortion—even if paid for with their own money. We need to make sure the final bill doesn't include this rollback of reproductive rights.¹⁰

• The Senate bill could discriminate against lower income workers. The current Senate legislation retains a version of what's called the "free rider" provision, which essentially penalizes employers for hiring lower income workers. This provision needs to be fixed before the bill is finalized.¹¹

Check out more about the House bill here and the Senate bill here or here, and see what the impact of reform would be in your state here. If you want to read the full bills, for the House, click here or here (PDF), and for the Senate, here or here (PDF).