Cleaveland: Health care on threshold of change

Cleaveland: Health care on threshold of change

December 31st, 2009 in Health

Our current health care system is unjust, unaffordable and inefficient. Efforts to improve this system have failed previously, coming within a hairbreadth of failing today. Even with the passage of a health care reform bill by the U.S. Senate on Christmas Eve, uncertainty remains as work begins on reconciling Senate and House bills.

Summaries of the two measures are lengthy. The two most accessible side-by-side summaries can be read on-line by accessing the Web sites for the Kaiser Family Foundation and the Commonwealth Fund. Here are some of the major themes addressed.

* Access to coverage. Each bill requires most U.S. citizens and legal immigrants to have health insurance. Each establishes state-based exchanges through which individuals and small businesses can purchase coverage. Both provide support for individuals and families earning up to 400 percent of the federal poverty level ($88,200 for a family of four). Both bills expand Medicaid eligibility. The two proposals differ in requirements and incentives for employers to offer health insurance. Tax credits for purchase of health insurance are provided for companies employing 25 or fewer workers.

* Individual mandate. Every citizen and legal immigrant must obtain health insurance. A yearly penalty is assessed those who do not.

* Health insurance exchanges. The House bill establishes a national exchange that includes a public option. The public plan would initially attract persons with pre-existing health problems. The plan would negotiate payment schedules with providers that would be no lower than Medicare. A state could opt out of the national exchange by offering its own insurance exchange. The Senate bill requires each state to set up an insurance exchange with no public option. At least one plan in an exchange must be non-profit. At least one plan must not provide coverage for abortions.

* Consumer-operated plans. Each bill includes provisions for facilitating non-profit, consumer-operated health insurance plans within each state and the District of Columbia (see Group Health Cooperative of Seattle, Washington for an example).

* Benefit categories. Both bills establish four levels of benefits, beginning with a basic plan covering essential services. The Senate bill creates an additional plan that provides coverage for catastrophic illness or injury for some individuals under age 30.

* Insurance requirements. Plans must guarantee issue and renewal of policies. Premiums can be adjusted based on age, area of residence, and number of family members. The Senate plan allows a premium increase for tobacco users. Lifetime limits on medical expenses are prohibited.

* Simplification. The bills promote standards for simplifying administrative and financial transactions. The Senate bill provides for an Web site that would use a standard format for presenting insurance options.

* Health care compacts. States may form interstate compacts or coalitions that would permit insurers to sell policies to all residents of the states in the compact.

* Medicare. Extensive changes affect Medicare Advantage programs (see Kaiser Web site). Other provisions establish an independent Medicare advisory panel (Senate bill) to ensure that expenditures do not exceed a specified rate of growth. An "innovation center" would study design and test new methods of providing and paying for care. The House version addresses wide geographic variations in Medicare payments.

* Comparative effectiveness research. Each bill establishes an agency to evaluate and to compare the effectiveness of various procedures and services. Each specifies that the results of these studies cannot be used to mandate or to limit care.

* Malpractice. States are encouraged through financial incentives to develop alternatives to the current system of dealing with medical error and litigation.

* Primary care. The House bill provides increased Medicaid and Medicare payments to primary care providers.

* Prevention and wellness services. Various encouragements are given for these services. Both bills require chain-restaurants and vending machines to provide full nutritional data on each item offered. Community health centers and school-based health centers are encouraged.

Complex regulations deal with the supply and training of physicians and with financing of the new programs.

Scare tactics and deliberate misinformation have been used by opponents of health care reform. As a many year participant in the health-care debate, I believe the proposal that will emerge from a blending of the two Congressional bills will set our nation on a new path of more effective, more affordable, and fairer care.

Contact Clif Cleaveland at