The Truth About Essential Health Benefits

I'll admit it. I was skeptical of the administration punting essential health benefits to states. But I knew there had to be more than just politics involved. So, I attended the Alliance for Health Reform's briefing, Essential Health Benefits: Balancing Affordability and Adequacy, on the Hill last week to expand my knowledge.  Presenters included: John Santa, from Consumer Reports; Janet Trautwein, from the National Association for Health Underwriters; Chris Koller, Rhode Island health insurance commissioner; and Kavita Patel, from the Brookings Institution. It proved to be a very informative and enjoyable session. I won't go into the basics of essential health benefits here, because I want to focus on what was emphasized at the briefing.

3 interesting take-away points:

1) Adequacy and affordability will be the big advantages. The law requires precise, understandable benefit language; clear limits and exclusions; and everyday understandable key definitions to make it easier for consumers to make informed decisions about their health insurance. One hurdle still being worked out, in addition to affordability, are standard definitions. For example, habilitative care: what does this even mean?  Habilitative care refers to the acquisition of new skills, say for an autistic child, as opposed to rehabilitative care, which is a regaining of former skills. However, there is not an industry-wide agreement on exactly what habilitative care consists of.

2) Although punting to states and using benchmarks sounded like political strategy, it is not something new and is already the standard for state CHIP. It provides a relatively quick method to create qualified plans that must be offered by the 2014 deadline. This allows for state flexibility, which is very much appreciated according to Mr. Koller (R.I. commissioner of health citing states' already overwhelming work load). Additionally, almost every state already has insurance benefit mandates. (ex: mammograms). The problem is that state mandates do differ from state to state, and the obvious end result is non-uniformity. However, the good news is that there is considerable overlap in mandates, so states largely cover the same benefits (Janet Troutwein, National Association of Health Underwriters).

3) Contrary to popular belief, the legislative intent was to NOT be very prescriptive and set out stringent rules. The intent was to strike a balance and set a floor instead of a ceiling as a result of a failed, very prescriptive Clinton bill in the 90s (Kavita Patel). So punting to states wasn't last minute strategery after all.

I'm personally very excited that these insurance reforms are taking place. It's about time our country's healthcare got a facelift. Interested in more? Webcast of the event is now available online.

The States' Contradiction

Not too long ago, I came across an article discussing Texas HMOs' strong and exponentially growing profits due to their Medicare and Medicaid niche. The numbers are particularly interesting considering Texas is one of 26 states challenging the constitutionality of health reform and has a national joke governor who would rather secede from the union than give in to the "evils" of federal government involvement. "Overall, Texas HMOs reported [a] net income of $404.1 million in 2010...." That's strictly profit from a greater than $12 billion dollar business. Clearly, there is serious need for such services in the state (and every state). While anti-big government Perry touted a nearly recession-proof economy, the state was substantially benefitting from federal programs.

At least not in 2012.

But Texas isn't the only state. I'm picking on it because the article reminded me of my time as a policy intern at the Texas health department (Yeah you read that right - I have Texas roots). The Austin office buzzed from 7 am until midnight daily with policymakers scrambling to apply for as many health reform grants as possible in an attempt to improve their population's abysmal state of health (Texas ranks 44th in national healthcare rankings). Meanwhile, down the street, the Attorney General prepared his case against health reform. Never mind that Texans need some sort of improvement to their healthcare system.

Which brings me to my point: contradiction. Why is there a such a disconnect between the data (and what the population needs) and state action? It is well documented that Texans are struggling on the health care front and that Medicare and Medicaid are big business for the state. And yet, the state is reaching for partisan ideals, and is not the only one doing so. Does it really just boil down to a political move?  Down the line, will this be another big lone star "Oops?"

Health Reform Animated

Part (probably a large part) of the problem for health reform is confusion. The public has no idea what the massive law even says and no understanding of health care jargon. ACOs? Exchanges? Individual Mandate? Uh, WTH? It's overwhelming, but understandably so. We're dealing with complex stuff here. It is a complex step forward in helping to solve a SUPER complex mess/system. Naturally, there is push-back to change and to something so difficult to grasp. So far, it seems like politics and political rhetoric have made decisions for the general public rather than genuine, informed position-taking even 2 years after it has been signed into law.

That's where our friends at the Kaiser Family Foundation come in.  They've created a short animated movie of the health reform law explaining, in cartoon, the pit-falls of our current health care system and the changes that have already been made as well as those that will come. While the feature flick is 1 year old, it is still entirely relevant and totally under-utilized. 

If you haven't seen it, check it out (English or Espanol): 

Health Reform: Ready, Set, Punt!

Punting, passing, and kicking issues down the field is a regular occurrence here in Washington -- what with handing the ball to states to define essential health insurance benefits, the several, almost government shutdowns, and Congress... well, enough said. But there is another under-reported, under-hyped potential play that could be called: punting the health reform ruling by the Supreme Court in 3 months.

Whoa. Game-changer. You mean there's a way to avoid making a life or death decision for PPACA and any political ramifications for Election 2012??

It all lies in the Tax Anti-Injunction Act. Simply put, the Act (which applies to more than what we usually think of when we say "tax") requires a person to have actually paid the contentious tax/penalty (whatever it is) before challenging it in court. However, the tax/penalty provision in PPACA does not kick in until 2015ish. Therefore, no one has yet paid it. How can there be a  challenge to something no one has been forced to do? Well, that is the argument -- that the claim at hand is premature and is not "properly before the court." That is... until 2015. This reflects the fundamental federal rule that an actual case or controversy must exist prior to judicial review (but in statutory form). The minute someone pays said tax/penalty, an actual case or controversy arises. Delaying Supreme Court review could favor health reform. It has been argued that greater time will yield a greater number of supporters as implementation is more wide-spread. So, the Court has a way to postpone deciding on the merits and reschedule the match-up if it so choses.

This issue has been allotted 1 full hour out of the 5.5 hours of oral argument, and is not without its weaknesses, but it will be interesting to see how this pans out in the super bowl of health reform litigation. Do you think the Supreme Court should postpone making a decision on health reform?

Hello 2012! Goodbye PPACA?

2012 is fast approaching. Every year seems to fly by more quickly than the last. What happened in 2011?

The erosion of health reform is what happened. Change began as a landmark, unprecedented reform to the healthcare system. Finally, something would be done about the ugly (and I mean grotesque) state of healthcare in our nation after many failed attempts over the decades by both executive and legislative branches past. It was set to be this administration's crowning jewel. The U.S. would no longer be on a fast-track to health care debt oblivion, and all the while the state of public health would improve. Sigh, such idealism.

But before the President even finished inking his name approving the law, PPACA was labeled "Obamacare" -- supposedly a universal health care system for socialist America -- and that was only the beginning. On came the plethora of lawsuits challenging its constitutionality; and in a few months, we will all know the law's final fate. However, even before PPACA has its day in high court, it lost a provision -- long-term care insurance. Voluntarily. And recently, HHS announced it will not be defining essential health benefits... states will. So, we will have 51-ish different versions of "essential benefits." Sure, it was politically genius (how will this tactical move affect Supreme Court oral arguments?), but is it smart policy? This punting will hinder the portability of health insurance. Wasn't the original intent to provide reliable, comprehensive coverage of benefits?

What began as a glittery promise of health care for our country now is fading. Literally. With provisions erased right before our eyes, what more will be scrapped in 2012? Granted, the law is not perfect and would have been tweaked anyway, but are we on a trajectory leading right back to the drawing board? Let's hope not.

Cheers to what 2012 will bring.

Health Reform Oral Arguments - Kind of a Big Deal

By now, I'm sure you've heard that the Supreme Court has scheduled hearings for the landmark Health Reform case in March. I'm sure you've also read that 5.5 hours have been allotted for said oral arguments. If not, 1) what rock are you living under? and 2) go here, here, and here. But a large chunk of the population spends 5.5 hours watching tv each day. Think about how much mind-numbing, eye-crossing CNN, Kardashians, Snookie and the Situation, Leno and Rachel Ray is consumed. So what's the big deal anyway?

Photos were not allowed, but this is what the interior of The Courtroom looks like from a model on display in the Holding Hall. Imagine being on the hot seat there. Intimidating much?

Let me help put this in perspective. Typically, the Supreme Court allows 1 hour of oral argument per case with each side given 30 minutes to present. I had the privilege of sitting in on a SCOTUS case; and let me tell you, half an hour is a fairly decent amount of time to talk (or rather...to be skewered and grilled by the justices). The justices, in most cases, have already made up their minds purely based off of briefs and research submitted prior to oral presentations and use that time to steer the presentation along their own agenda to make a point and perhaps sway other justices to decide a certain way. With that being said, 5.5 hours is FIVE and a half TIMES greater than the usual. Even one of the most important and controversial modern cases, Bush v. Gore, did not come close. That case single-handedly determined who the president of the United States would be, and oral arguments were limited to merely 90 minutes (see video). 90 minutes for the presidency compared to an epic 330 minutes for Health Reform. Hmmm.

Why does the Court need this much time considering they usually have their minds made up? Is this bad news for President Obama, Democrats, liberals, and supporters of Health Reform everywhere, because maybe it shows that the Supreme Court will not have an open and shut case? Or is the Court just attempting to have a fair presentation of extremely complex issues? What are your thoughts?

"Slackers," Health Coverage, and Open Relationships

Recently, news outlets like USA Today widely reported that 2.5 million new young adults now have health insurance attributable to PPACA. Hooray! That is wonderful news, right? Well, think again. From another perspective, it is not exactly cause for celebration. I came across an interesting blog entry written by Professor and Dean Vickie J. Williams of Gonzaga Law who stated that this need to be on parents' health insurance plans is "not a sign of a robust private insurance market." Instead, it really, "highlights the continued stagnation of the job market."  Great, more proof of a morbid job market. 


Additionally, she poses the idea that we as a society should sever the relationship between work and health insurance. I hadn't before seriously thought about such a concept since health insurance had been so intimately linked to employment my entire life. This monogamous marriage just turned into an open relationship. Consider.mind.blown. But it is nonsense to think that those who do not have a traditional job are "slackers" or somehow unworthy of health insurance. Professor Williams believes that the dependency of health insurance on employment stifles job freedom, risk-taking, innovation and creative productivity. Are we holding back a generation? Why do we have the system set up the way it is anyway? She traces the outdated employer health insurance model back to the WWII era -- a period when folks worked at the same company until retirement (basically ancient history...does that even exist today?) and employers received serious tax benefits. 


Times have really changed. So should health coverage.