As 2010 comes to a close, The Century Foundation has once again charged us with composing a “Best of/Worst of” list to recount the year’s highs and lows in health care. I am off for vacation tomorrow so my list is still under construction—to be completed at the beginning of the New Year. But as I sit here thinking (TCF is, after all, a think-tank so that is what we’re actually paid to do) it strikes me that 2010 started off with a frantic battle: the last major push in Congress to get enough votes to pass the Patient Protection and Affordable Care Act. After a long and bruising battle in Congress that included strident opposition from most Republicans, the bill squeezed through and was signed into law by President Obama on March 23.
What followed was relief (and a bit of exhaustion for those of us who for months had been writing ferociously, and in the case of Maggie, optimistically, about the bill). There was also a sense of accomplishment and satisfaction that we were finally on our way to achieving affordable, comprehensive health care in this country.
That was a long nine months ago. The optimism that was so palpable in March has now been replaced by a renewed sense that the fight for health reform has begun once again (or maybe it never really ended). Even before the Affordable Care Act (ACA) was passed, several states including Utah, Virginia and Idaho had passed laws blocking the individual mandate, the basic tenet of health reform that requires most Americans to have health insurance or pay a penalty. The individual mandate is integral to the legislation because it requires everyone—healthy, sick, young, and old—to be in the “pool” so to speak. Without the mandate, many young, healthy Americans might decide to forgo insurance—gambling that they won’t be the one to have an accident or be diagnosed with a serious illness—and leave the exchanges to older, sicker and disabled individuals who will face far higher rates. When those “young invincibles” and other hold-outs do get sick or injured, the rest of us will have to shoulder the burden of their care—much as we do now.
Earlier this month, a Virginia District Court handed down a decision that found the individual mandate unconstitutional. Meanwhile, two other courts have upheld the mandate as constitutional, so most experts believe the issue will end up being decided by the Supreme Court. Among constitutional scholars, there is optimism that the mandate will stand, but it will be a long, shrill journey toward any resolution.
This year also saw Republicans warning that they will use the power of the purse as well as the law to block health reform implementation. Senate minority leader Mitch McConnell has said that “starving health care reform” should be a major goal for Congress in coming months. We are seeing the first glimmer of what that kind of obstinacy looks like. Last week Congress blocked Obama’s $1.1 trillion budget plan that included some $1 billion in funding to help federal agencies gear up for extending health reform’s many provisions. Today, Congress is close to passing a $250 billion spending bill that expires March 4 and avoids budgetary deadlock; but the bill conspicuously excludes funding for health reform (or financial reform, another aspect of Obama’s domestic agenda that is opposed by many conservatives). Congress—with its new Republican advantage in the House—will take up the budget bill, and thus, the issue of “starving the beast” that is health reform next year.
As that process starts up again, it is vitally important that the administration begin a two-pronged campaign to turn that demonic “beast” into a more benign and protective creature. First of all, the President needs to call attention to the important provisions of the health reform legislation that have already been enacted. A brief time-line looks something like this:
The Affordable Care Act authorizes $250 rebates to seniors who hit the “donut hole” in Medicare’s prescription drug coverage
Under the Early Retiree Insurance plan, the government provides $5 billion to preserve employer coverage for early retirees who are not yet eligible for Medicare
Young adults may now stay on their parents’ plan until they reach 26 (or receive benefits from their employer) All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance.
Insurance companies are prohibited from “rescinding” coverage from subscribers (by finding a minor error in their original application) once they get sick with cancer or are affected by another serious problem.
Insurers are prohibited from imposing annual and lifetime dollar limits on essential benefits, like hospitalization for most subscribers.
Insurers cannot deny coverage to children under 19 because of a pre-existing condition
The Department of Health and Human Services issued new regulations that require health insurers to spend 80 to 85 percent of consumers’ premiums on direct care for patients and efforts to improve care quality. This regulation, known as the medical loss ratio, will take effect in January. In 2011, the new rules will protect up to 74.8 million insured Americans and estimates indicate that up to 9 million Americans could be eligible for rebates starting in 2012 worth up to $1.4 billion.
For inexplicable reasons, there has been little fanfare about these important changes and protections for consumers. Polls find that although consumers say they support these new provisions, opposition to the actual health reform legislation remains unchanged. A December 12 poll from the Washington Post and ABC News found that 43% of Americans support health reform legislation, while 52% do not. Kaiser’s latest Health Tracking poll found that 42 percent of Americans say they have a generally favorable view of the law, while 41 percent have a generally unfavorable view of it. So, basically, the overall trend is that support for the bill remains “tepid” or “mixed.”
Besides trumpeting its own horn more effectively, the government also needs to jolt Americans out of their complacency when it comes to the current state of health care. A bleak picture is emerging of a nation where there are now 50 million uninsured; and another 25 million or more whose policies are so bare-bones that they risk medical bankruptcy with just one serious illness. Medicaid rolls have risen sharply in many states to a total of 48.5 million last December; further burdening a safety net system that is strained to the point of breaking. Arizona’s decision to stop paying for many organ transplants for its Medicaid beneficiaries is just the starkest example of the rationing taking place in these programs that includes trimming enrollment, raising cost-sharing and canning child health programs.
Health insurance premiums are rising; some consumers are going to find limits on the number of doctor visits and other new restrictions on care in months to come. The most controversial—but arguably, most important—changes in health care will not go into effect until 2014. That’s when states will need to have insurance exchanges in place, Medicaid expansions must be complete and the individual mandate is scheduled to go into effect. If this year is any indicator of how all this will play out, we have a rough road ahead.
As I reread this post, I realize that the “Best Of” aspect of my year-end round-up needs to be fleshed out a bit; I must try to find more glimmers of hope among the threats, disappointments and hyperbole that currently surround the health care and policy areas. The voices of repeal, restrict and defund are very loud and winning out for now. But it is also true that individual states—including Virginia—are beginning to design the frameworks for health insurance exchanges; they are working on new ideas for expanding Medicaid; experimenting with the concepts of accountable care organizations and defining best practices. I plan on looking into these glimmers and innovations in coming months and welcome any suggestions you, our erudite readers, have for completing the Best and Worst list for health care this year.