Sugar on Shit, or Underinsuring Is Not a Solution
Today, I stumbled across a short, poorly written (and researched) news story on a bill proposed by US Senator Enzi (R, Wyoming) that risks obliterating some of the hard won minimum mandatory coverage laws at the state level. The bill - "The Health Insurance Marketplace Modernization and Affordability Act" should really be called "The You Can Put Sugar On Shit But That Don't Make It A Donut Act". It came from the US Senate Health, Education, Labor, and Pensions Committee, which Senator Enzi co-chairs. Sen Burns, Conrad R. (MT)
I spent some time today researching this bill, then I spent some more time writing to my senators begging them to defeat it.
One of the most salient features of S. 1955 "The Health Insurance Marketplace Modernization and Affordability Act” is that it could remove or weaken coverage for medical services which are mandated in many states. Currently, quite a few states have laws which mandate coverage for certain medical services. Some examples are mammographies for breast cancer screening (49 states), colorectal exams for prostate cancer screening (22 states), and cervical cancer screening (29 states). Other examples of state based mandatory coverage include: well child check ups and immunizations, same sex partner benefits, breast reconstruction post mastectomy, post partum hospital stays, treatment of neuro-lyme disease, access to chiropractors, and prescription contraceptives. There's a nice by state list here given in terms of what mandatory benefits could be lost under the provisions of S. 1955.
Having done some health insurance lobbying for graduate assistants at the state level in CT, I know that many of us take our state's mandatory coverage policies for granted. Often, people don't even realize that coverage for our glucose monitors or pap smears are considered hedonistic luxuries by our insurance carriers. But if you live in a state that does NOT have mandatory coverage for a service you need, you do realize it fast. If you're faced with an insurance change where something you need is unexpectedly not covered, you realize it fast.
More of us may find ourselves realizing it fast if the "Health Insurance Marketplace Modernization and Affordability Act” (S.1955) passes. The bill is being promoted as a way to provide insurance to more people by
(A) the creation of "small business health plans" and
(B) the "modernization of the health insurance marketplace".
Let's take a closer look at those goals.
A) What are "Small Business Health Plans"? Small Business Health Plans (or SBHPs) are a good idea in theory. The S. 1955 bill summary defines them as "group health plans sponsored by trade, industry, professional, chamber of commerce or similar business associations". The idea is that small business owners would be able to pool together into larger groups and buy affordable (for the business) coverage for their employees. That sounds nice, doesn't it?
But wait, there's more! These SBHPs would be overseen at the federal level by the Secretary of Labor. This measure would effectively move regulation of access to health care (such an intimate thing) for people covered by the SBHPs a massive step away, in the competent hands of the federal government. So if you had to appeal a decision by your insurance carrier under a Small Business Health Plan, you'd be looking, quite literally, at having to make a federal case. We need only consider some of the past year's headlines to see how well the inner offices of the federal government manage their - um, I mean our - business (here's a small set of examples 1, 2, 3, 4).
Too bad for the people who would be covered by the SBHPs, right? If you're thinking this, you're silly, just silly. Because S. 1955 would also allow "other plans to be treated as small business health plans under certain circumstances." You have to wonder what those circumstances might be. Does that mean my NON-Small Business Health insurance Plan could become treated as if it were an SBHP "under some circumstances"?
B) "Modernization of the health insurance marketplace" is the nail in the coffin, the straw on the camel. It takes the cake with the cherry on the sundae. I must admit, I can barely understand some of the summarized provisions. And god help me my eyes feel like they will bleed when I look at the bill text. BUT....Here's what is 100% clear even to my extremely ignorant and naive browsings. Part of the "modernization" means the creation of a set of coverage requirements that would be mandatory for all of these plans, in every state. The set of mandatorily covered benefits would be created by looking at existing mandatory coverage laws in all states. Under S. 1955, the newly created Small Business Health Plans and any plan treated like a Small Business Health Plan would only have to cover services that are mandated in 45 out of 50 states. If your state mandates coverage for something that even 44 other states also mandate, then you are out of luck. No more guarantee of coverage for you. I hope your kid doesn't really need well child check ups.
Here's a real world example. Fewer than 45 states mandate that diabetic supplies (e.g., glucose monitors) and diabetes education (e.g. nutrional counseling, insulin pump instruction) be covered. Thus, even in states that mandate coverage of diabetic supplies or diabetes education, the SBHP-type insurance would not have to cover diabetic supplies or diabetes education.
Or pap smears, or prostate cancer screening, or ovarian cancer screening, or contraceptives, or hospice care, or substance abuse treatment, or home health care, or well child care, or second opinions, or ambulance transportation, or bone density screening, or minimum mastectomy stays, or late stage lyme disease treatment, or rehab services, or hearing aids, or special formulas, or prosthetics...
Go here for a state by state list of mandated benefits that would be at risk in SBHPs under S. 1955.
Underinsuring people is a simply horrible idea. It's not just horrible for the uninsured, the people the bill's creators claim it will help. Underinsurance sucks universally because it drops the standards of insurance for everyone in the "insurance marketplace". Lower insurance coverage leads to lower standards of care. This can happen indirectly, but in the case of this bill it is sensible to be concerned about it happening directly. Even if the "circumstances" under which a non-SBH insurance Plan could be treated as an SBHP were to be very narrowly defined, the bill still includes language for extending SBHP privileges such as dumping state mandated coverage to nonSBHPs.
Further (and this is going to sound so utilitarian, in the most negative way), consider that providing people with shitty insurance that skimps mostly in the preventative (or preventable disease) care means you have just put into the health insurance population a pool of people who are pretty much guaranteed to be at higher risk for developing expensive health problems than well insured folks are. Early diagnosis, education about and access to tools for self care, good post-op or post procedure care, multiple treatment options, home health care for acutely or chronically disabled individuals, and accessibility to routine physical exams and vaccinations all help healthy people stay healthy and help keep health problems manageable. Underinsured people have less access to all of these services. Therefore, an outcome of a lack of access to services such as these is an increased risk of becoming sick enough to require hospitalization, surgery, and other very expensive health care use. There are only two option in this sort of scenario. Shared burden of these individuals (spread out to all health insurance consumers) or dumping of more covered services. The financial and social costs of a measure like this make it completely untenable as a solution.
Why is this not obvious to the people who sponsored this bill? Oh I don't know. Maybe they have other things on their minds. The graphs below each S. 1955 co-sponsor's name show contributions by sector (in thousands) to that senator. With a few exceptions, the longest lines are associated with contributions from the insurance sector. You can look this information up for yourself at a marvelous website called OpenSecrets.org
Sen Allard, Wayne (CO)