Health Insurance and You!

Last year, we followed AB 52, a California Assembly bill that would allow state officials to regulate health insurance premium increases, similar to the way they regulate car insurance premiums. Introduced by Assemblyman Mike Feuer in December 2010, the bill was debated by the state Senate Appropriations Committee in August 2011, but in September, failed to get enough votes to pass the state Senate and become law. Although the bill has been proposed and then nixed for the past four years, Assemblyman Feuer plans to continue bringing it back to the table.

This year, his effort may get a boost on the national scale. U.S. Senator Dianne Feinstein has been designated the chief spokeswoman on the issue, according to an article by Marc Lifsher of the Los Angeles Times. Sen. Feinstein was the first person to sign a new petition to put state regulation of premium increases on the ballot this November, a campaign that will require 505,000 signatures to succeed. She then spread the word on the issue by emailing the petition to about two million constituents, encouraging them to sign it as well.

Sen. Feinstein’s email focused on you – the individual market – as the main group of consumers who the bill would protect from rising premiums. People enrolled in employer-sponsored plans, she explains, are less affected by rate increases since their premiums are at least partially subsidized. Her website’s healthcare section goes into more detail, citing some of the highest proposed rate hikes of the recent past and the fact that about two-thirds of states and the District of Columbia already have the authority to regulate premium increases.

This isn’t Sen. Feinstein’s first involvement with the issue. Last August, according to a press release on her website, she testified before a Senate Committee on a proposal that would prevent health insurance companies in all states from increasing rates without justifying them.

Readers, do you think that bringing national attention to the issue will help the California proposal? Do you agree that health insurance premium increases should be approved by the state?

Last Thursday, the California state Assembly passed a package of bills that if enacted, would broaden private health insurance coverage, especially as it relates to mental health. According to an article by Judy Lin of the Associated Press, those bills include:

• AB154, which passed 47-18, and would require health insurance companies to cover the diagnosis and treatment of almost all mental illnesses. This includes nearly 400 conditions.
• AB171, which passed 45-13, and would require insurers to cover developmental disorders, such as autism. This is already a requirement, but is not always followed.
• AB137, which passed 67-0, and would require insurers to cover mammograms for all patients who need it, regardless of their age.
• AB1000, which passed 51-15, and would require insurers to cover oral chemotherapy as extensively as they cover intravenous chemotherapy. Similar laws already exist in 13 states and the District of Columbia.

Proponents of the expansions to coverage say that people with mental health conditions are often unable to get treatment, and so they cost taxpayers money through public health programs and when they need emergency care. Assemblyman Jim Beall, who proposed AB154 and AB171, believes that this is a more cost-effective approach because patients will be treated before an emergency takes place, Ms. Lin writes. Plus, supporters say, physical and mental health are equally important to overall well-being, and thus should be covered at similar levels.

Opponents argue that these bills place a large burden on health insurance companies and will drive up their costs, which will be passed on to consumers in the form of higher premiums and fees. They also say that it may encourage abuse of prescription drugs such as medical marijuana.

These four bills are now headed for the state Senate.

In a little under two months, the Supreme Court will begin hearing arguments for and against the constitutionality of 2010’s Affordable Care Act. At the center of the debate is the individual mandate, the requirement that all Americans maintain health insurance coverage. Opponents of the overhaul say the mandate encroaches on people’s right to buy the products and services they want. Supporters believe that without insuring everyone, the rest of the law will be less effective.

But on Friday, the Obama administration announced to the Supreme Court that most of the law can still survive, even if the individual mandate is thrown out. Those portions include cost control measures and public health efforts that are unrelated to insurance coverage, explains James Vicini in an article for Reuters. Plus, they say, the Supreme Court has never before struck down a comprehensive law like health reform because one provision was unconstitutional.

If the individual mandate is invalidated, two parts of the law will have to be eliminated: first, that insurers cannot refuse to cover a person with pre-existing medical conditions, and second, that insurers cannot base a person’s premium cost on his or her medical history. This would protect insurance companies, who need the income from healthy customers’ premiums to pay for the medical costs of the less healthy. Without the individual mandate, those healthy customers may choose not to maintain coverage.

For more information and previous coverage of this debate on our blog, please read:

• Jan. 6, 2012: Cameras in the Courtroom: Will Supreme Court’s Hearing of Health Reform be Televised?
• Nov. 14, 2011: Confirmed: Supreme Court Will Rule on Health Reform
• Nov. 11, 2011: D.C. Appeals Court Rules in Favor of Individual Mandate
• Nov. 4, 2011: Insurers Worried about Potential Repeal of Individual Mandate
• Additional posts about health insurance policy and regulation

Last summer, we blogged about new, standardized forms created by the National Association of Insurance Commissioners that aimed to simplify the health insurance shopping process by allowing insurers and plans to be compared directly. Much like food nutrition labels, the four-page forms included charts listing the costs of common procedures for in-network and out-of-network providers, sample calculations for three scenarios, and definitions of common insurance terms. The new forms would not replace the longer booklets that currently describe plans, but instead, would serve as a supplement.

When the U.S. Department of Health and Human Services (HHS) unveiled these forms in August, the goal was to have them ready by March 23 of this year. But several health insurance companies, who would be the ones developing the forms, wanted more time, according to an article by Susan Jaffe of Kaiser Health News. Insurers argued that the March deadline would force them to duplicate efforts and create both styles of forms for plans available in 2012: once, in the usual format, for continuing enrollment at the end of 2011; and again, in the new format, for those enrolling in March or later. If the deadline were pushed back, they said, they could use the old format for 2012 and begin using the new one in 2013.

Now, writes Ms. Jaffe in a new article, questions still remain about how exactly the forms should be used. HHS is still reviewing public comments on the sample forms. Given that the March deadline is less than two months away, it’s likely to be pushed back. But advocates for consumers and seniors urge HHS and the Obama administration not to weaken it. Several organizations, including the American Cancer Society, Consumers Union, and AARP, have written and signed an open letter to the president asking for the forms to be available by this fall, in time for enrollment for 2013. The letter also asks that the forms include premium and cost information as well as examples, and that they be required for group and individual market plans.

The Supreme Court case pitting 26 states against the health reform law has received a lot of attention in recent weeks. But in the meantime, many of the same states have been making progress in building online health insurance exchanges, a key component of the 2010 overhaul. In fact, the Department of Health and Human Services (HHS) announced on Wednesday that 28 states and the District of Columbia have moved toward creating the exchanges, in spite of the legal challenges to the law and political opposition to it in many states.

According to an article by David Morgan of Reuters, 14 states have established their authority to set up exchanges, whether by a new law or one that previously existed, and 14 have taken steps to show that exchanges are useful. The health reform law set a deadline of January 1, 2013 for states to either move toward a state-based exchange or agree to participate in a national one, with the option of later establishing a state-based system. The exchanges must be up and running by the beginning of 2014. But given the uncertainties and Supreme Court hearings scheduled for this spring, some states have decided to wait and see what happens.

However, all states have made some changes since the law was passed. For example, writes Meghan McCarthy of the National Journal, 44 states have strengthened their review of increases to health insurance premiums. In addition, most states have accepted federal grants to help them plan for the exchanges, says Louise Radnofsky of the Wall Street Journal’s Washington Wire blog. According to Julie Appleby of Kaiser Health News, those grants total more than $729 million in 49 states and D.C. (only Alaska has not sought funding). Some states, however, do not plan to use their grants and will return the money.

During the past few months, we have covered the story of the Community Living Assistance Services and Supports (CLASS) program, health reform’s program for long-term care insurance. While it was being debated and in the months following its enactment, various groups and analysts expressed doubts about whether the program could pay for itself. (Last year’s health overhaul required CLASS to be solvent for at least 75 years, explains Igor Volsky of Think Progress). Last October, echoing those worries, the Obama administration decided to drop the program.

Now, the formal repeal of CLASS is proceeding through the legislature. In November, the House Energy and Commerce Committee voted in favor of repeal. And yesterday, writes Sam Baker of The Hill, the House Ways and Means Committee voted the same way. The next step is a House floor vote, which will take place next month.

While Congressional Republicans are largely against the program and the health reform law in general, Mr. Baker says, Democrats say that CLASS targeted a serious problem – the fact that most Americans are unprepared for the expenses of long-term care – and that while this particular program was not viable, the government should continue to search for an alternative that is more financially sound.

Although CLASS was dropped, not everyone supported its outright repeal, Mr. Volsky elaborates. Many of those who supported the intent of the program were against its repeal, arguing that it could instead be modified and its financial model strengthened. But those in favor of repeal believe that it needed to be removed formally and legally, rather than simply abandoned, Mr. Baker writes.

Neither home care nor nursing home residency are covered by Medicare. While CLASS is no longer an option for those who may need long-term care, a variety of affordable long-term care insurance plans are available on the individual market. If you’re interested, our reference page on long-term care is a good place to get started.

During the past couple of weeks, much public attention (and TV airtime) has been devoted to the Republican Party debates. Kaiser Health News has compiled videos and transcripts of the candidates discussing health care and health insurance issues, and below, we use those resources to summarize what each candidate had to say. In alphabetical order:

Newt Gingrich

• On health cost control: Former Speaker Gingrich supports the Ryan/Wyden health bill, which expands consumers’ options for Medicare. He would also push for improved surveillance of health criminals, citing data that Medicare and Medicaid lose $100 billion per year to theft.

Jon Huntsman

• On health cost control: Gov. Huntsman agrees with Paul Ryan’s budget, which would cut the budget by about $6.2 trillion over ten years and would affect all programs, including Medicare and defense. He also supports means-testing for entitlement programs, including Social Security and Medicare, among the wealthiest Americans.

Ron Paul

• On contraception: Rep. Paul explains that the Fourth Amendment protects’ privacy, which can be extended to contraception, and the Interstate Commerce Clause protects the right to sell contraceptives across state lines.
• On health insurance: Paul believes that seniors should have the same variety of health coverage that other adults have – including a similar range of comprehensiveness and cost. Later in the same debate, Paul distinguishes between entitlements and rights, stating that the only type of right is the one to liberty.

Mitt Romney

• On contraception: Gov. Romney states that no state wants to ban contraception, and that he can’t imagine any state doing so. As to whether states have the right, he does not know and considers the question irrelevant. However, he does believe that the Supreme Court should overturn Roe v. Wade, the landmark 1970s abortion case.
• On health cost control: Romney supports shrinking the size of government and its spending in order to reduce costs. By cutting health reform, he says, the government would save $95 billion per year and businesses would save as well.

Rick Santorum

• On contraception: Sen. Santorum believes that while privacy is protected under the Constitution, Roe v. Wade is not about privacy and should be overturned.
• On health cost control: Santorum supports means-testing for entitlement programs such as and reducing subsidies for the wealthiest Americans. He also believes that in order to reduce dependency, food stamps, Medicare, and housing programs should no longer be entitlements, and should instead be managed by the states as block grants. Beneficiaries should be required to work and should only receive benefits for a limited time.
• On health insurance: Santorum has supported health savings accounts for many years, in order to make the private sector health care system more “bottom-up” and consumer-based. He cites the Medicare Advantage program and Medicare Part D, which have transformed Medicare, as more examples of the premium support model he believes in.

See video and transcript on contraception (ABC News/Yahoo debate).

See video and transcript on other issues (Meet the Press debate).

Universal health care in Massachusetts, established through a major overhaul in 2006, just became a little more universal. On Thursday, the state’s highest court ruled that legal immigrants are entitled to the same health insurance subsidies as citizens. The case was filed by the Boston-based firm Health Law Advocates.

According to an article and radio broadcast by Martha Bebinger of WBUR, the ruling affects about 40,000 residents and may cost the state $150 million or more. Commonwealth Care, the state’s insurance program, currently costs about $822 million per year, writes Chelsea Conaby in an article for the Boston Globe. Massachusetts receives federal help with the cost of care for citizens but not legal immigrants, although that will change when health reform is fully enacted in 2014. Thursday’s ruling does not affect illegal immigrants, who are still not eligible for coverage through the state program.

It may be surprising that this wasn’t always the case. Ms. Bebinger explains that Commonwealth Care subsidies for legal immigrants were eliminated as the result of a tight budget in the spring of 2009. At the time, the decision saved about $130 million, according to an article by Jess Bidgood of the New York Times. As a result, the state created a separate insurance plan for immigrants known as the Commonwealth Care Bridge Program, which cost only about $40 million. But that plan, Ms. Conaby writes, had higher co-payments and a smaller provider network, and did not cover vision, hospice, or skilled nursing care. Plus, it was only open to people who were dropped from Commonwealth Care, thus excluding new legal immigrants.

While legal immigrants and their advocates are celebrating the decision, the state is debating how to pay for it. Ms. Bebinger lists some of their options, which include increasing taxes or fees to fund the program, scaling back other programs, or cutting health insurance subsidies for all residents. Whatever the decision, it will have to be included in Massachusetts’ budget for fiscal year 2013, which will be filed in the next few weeks.

Whether or not Supreme Court cases should be televised has been debated many times over the years. And since the Bush vs. Gore presidential election case in 2000, no Supreme Court case has had the level of public interest as the fate of 2010’s Affordable Care Act, for which five and a half hours of oral arguments were recently scheduled for March 26-28 of this year.

Now that the arguments have been scheduled, speculation has sprung up again about whether the case will be shown on TV. Recent surveys show the public leaning towards yes. One poll by USA Today and Gallup, reports Joan Biskupic of USA Today, found that 72% of respondents supported allowing cameras for the health reform arguments, with a majority supporting broadcast of Supreme Court arguments in general. Similarly, writes Joe Palazzolo of the Wall Street Journal’s Law Blog, a poll of the blog’s readers found that 55.6% favored televising the arguments.

So what are the issues at stake? Those who support televising Supreme Court cases, which include some members of Congress and media leaders, say that it would educate the public and encourage interest in what the Court does. Being able to see cases in their entirety, rather than reading someone else’s summary, would allow individuals to interpret the arguments on their own. Proponents also mention that written transcripts and audio recordings of oral arguments are already available soon after they take place – and in some states, video.

Those who don’t want the health reform case broadcast argue that televising one case would put pressure on the Court to televise other cases. They also worry that politics would enter the picture, and that choice sound bites that don’t necessarily show the whole picture would be taken out of context. Having a camera in the room may change the dynamics between Supreme Court justices, who will know their every move is being watched. In addition, some say that televising arguments would go against the constitutional separation of powers.

As of now, C-SPAN and 46 other media organizations have requested that the Supreme Court allow the case to be broadcast. The Court has not yet responded.

Readers, what is your take on this issue? Should the health reform arguments in March be televised? Should all Supreme Court cases be shown on TV?

As you’ve probably noticed on this blog, 2011 has been a big year for health policy developments at the national, state, and local levels. In the health insurance world, we saw progress by the states in crafting online health insurance exchanges and steps toward implementation of last year’s health care overhaul. Journalist Ezra Klein, in his Washington Post blog Wonkblog, posted a good roundup yesterday of 2011’s health policy highlights, which we supplement below with milestones that we’ve blogged about.

Health Reform and Nationwide Changes. The Affordable Care Act included several provisions scheduled to take place between 2010 and 2014, many of which began this year.

• In January, Republicans in the U.S. House voted to repeal the health reform law (Washington Post, Jan. 19).
• In February, the Department of Health and Human Services (HHS) ruled that college health insurance plans had to comply with health reform’s requirements. Previously, they were exempt (GetInsured.com blog, Feb. 15).
• To commemorate Mother’s Day in May, HHS secretary Kathleen Sibelius highlighted four parts of the overhaul that aim to improve women’s health (May 13). In August, health insurers were required to begin covering women’s preventive care, such as contraception and screenings, by the following August (Aug. 1).
• Also in May, HHS decreased premiums and eased enrollment processes for federally-administered preexisting condition health insurance plans (June 6).
• In June, HHS moved toward phasing out ‘mini-med’ health insurance plans, which are inexpensive but have very limited benefits, by setting a September deadline for waiver applications (June 21).
• In July, HHS awarded low-interest loans to non-governmental groups to help them introduce Consumer Oriented and Operated Plans, also known as co-ops (July 20).
• Health reform originally included a long-term care insurance program known as CLASS. In October, however, officials deemed the program financially unviable, and decided to drop it (Oct. 21).
• Courts and experts continued to debate the constitutionality of the individual health insurance mandate. In November, a D.C. appeals court ruled in favor of the mandate (Nov. 12) and the Supreme Court announced that it will rule on the case in early 2012 (Nov. 14).

Health Insurance Exchanges. The federal government and states came closer to shaping online health insurance exchanges in 2011. The exchanges are set to launch in 2014.

• In August, HHS unveiled standardized health insurance forms to simplify the insurance shopping and selection process (Aug. 17).
• The Institute of Medicine and HHS worked to define what health benefits are considered ‘essential’ (Oct. 11), but ultimately, HHS decided to leave that decision to the states (@GetInsuredCom, Dec. 29)
• In December, Minnesota launched demos of several health insurance exchange modules for public comment (including one developed by us!) (Dec. 12).
• States voted on whether to use the federal exchange or establish their own, set up exchange committees, and took other steps forward during the past year. Many of these are noted on our Twitter feed.

Medicare and Medicaid. These programs for the elderly and poor were often threatened due to a tough economic climate, but they made some innovative and interesting changes.

• In April, Medicaid announced a new grant program for states to incentivize healthy behaviors, like losing weight and quitting smoking, that reduce health costs (Apr. 13).
• In December, Rep. Paul Ryan and Sen. Ron Wyden proposed a Medicare reform plan that would provide seniors with subsidies to enroll in a public or private insurance plan (Washington Post, Dec. 14).

State Changes. At the state level, lawmakers enacted a variety of policies designed to improve health, including many related to health insurance.

• In January, Michigan voted to provide health benefits to domestic partners of its state employees (Feb. 9).
• During the first few months of the year, states established open enrollment periods for child-only health insurance plans (Mar. 8).
• In April, Massachusetts proposed a method of dealing with the rising cost of healthcare by replacing the traditional fee-for-service model with integrated care (Apr. 19).
• States began implementing the medical loss ratio rule, which required insurers to spend at least 80% of premiums on care or quality improvement. In July, five states got more time to put this new rule into effect (July 25). In December, despite lobbying by insurance brokers, HHS defined broker fees as an administrative cost, not falling under that 80% (Dec. 5).
• In September, after several months of debate, California voted against state regulation of health insurance premium increases (Sep. 1).
• Also in California, in October, lawmakers passed a bill to require individual-market plans to cover maternity care starting in July 2012 (Oct. 7).
• In November, New York mandated health insurance coverage of autism screening, diagnosis, and treatment starting in November 2012 (Nov. 2).
• Health insurance companies continued to propose premium increases, many of which were met with criticism. In November, HHS ruled for the first time that one Pennsylvania insurer’s proposed increase was unreasonable and asked the company to justify the increase (Nov. 22).

Mr. Klein writes that “in health policy, 2011 might be best viewed as the year of getting ready.” Looking at the policy topics we’ve covered during the past year, he may be right: several bills were passed and committees convened, but their implementation and action won’t get rolling until 2012 and later.

Readers, as 2011 draws to a close, what are your thoughts on this year in health? Did we make the kind of progress you hoped to see?