Key National Topics

Update on Health Insurance Market Reform
by Malina Maneevone - Nurse Anesthesia Resident Samuel Merritt University

On the last day of our AANA campaign to Washington DC, Zach Langton and I were able to sit in on a Ways and Means committee hearing. Although I had taken a health policy course and have been following the evolution of healthcare policy over the last year, this week carried the intensity of an immersion course on policy. If you are DC-savvy, jump ahead. Otherwise this is the skinny on what I learned.

There are three major committees that will write/rewrite healthcare policy:
1.  The Ways and Means has a subcommittee responsible for Medicare issues.
2. The Energy and Commerce committee that has a subcommittee on health.
3. The Appropriations committee deals with the appropriation/appointment of monies such as how the $215 million designated to healthcare nursing workforce is split up between the different areas of nursing education. CRNAs are asking for $4 million of the pie. If you think that’s a lot, consider the appropriated $7 trillion designated for physician education dollars.

Presently the committees are conducting hearings, inviting expert witness to testify on their specific issues and recommendations for healthcare reform. After these hearings a bill will be written (May/June) and introduced to the House where it will go through lots of hoops to get passed, rewritten and re-passed (July/August) signed by President Obama and then given to CMS (around September) who finalizes the language that dictates the details of how it is enforced/enacted starting January 2010. Although this is an ambitious time line, healthcare is on the front of people’s minds and politicians are committed to the imminent nature of this (unwritten) bill.

Every point of this timeline is critical. Language can be included, excluded or changed at any point along the way that affects CRNAs and we must be ready to catch it and respond. The AANA’s goal for national healthcare reform is for non-discriminatory language. Thankfully we have excellent lobbyists in the DC office that are watching policy development to catch language or policy changes that threaten our profession. It is our responsibility to respond with letters/calls to our representatives when the AANA sends an alert and communicate to our representatives how they can support us. Without getting their attention, our representatives have so much going on they won’t catch the changes, even if they are supportive of midlevel practitioners.

The comments from Stark, Subcommittee Chair began, “There is no question that there is a serious national problem. The private market is not working.” He acknowledged the obvious bipartisan tone in the room. No one is trying to debate this any longer. There was however plenty of debate for the answer. There are essentially 3 options; status quo, expanded healthcare with a “public option” (with or without a mandate where public/Medicare type and private insurance is bought on a National Health Exchange) and Single Payer. Neither of the first or third option has enough support from President Obama nor from House and Senate to be viable. The argument for a PHP is: it already in place and offered to government employees in each state, inclusion of everyone will drive down cost not just by marketplace competition but by increased pooling of risk. Competition would not only decrease cost but would provide incentives for innovation within insurance companies. Arguments against PHP are that a less expensive Medicare option would shift costs (thus the term “cost shifting”) to private insurers. We understand and rely on this principle in anesthesia reimbursement, as we know a good payer mix means a mix that includes private health insurance because they pay at a higher percentage rate than Medicare and even more than Medical patients.

A small business owner, a community healthcare CEO, a health insurance CEO, a health policy analyst from Princeton and a consumer affairs analyst presented testimony. Each expert was given five minutes to present and followed by questions/comments from the ways and means committee. Here are highlighted points presented by each party as a way of summarizing the current discussions around Medicare’s role in future policy:

Uwe Reinhart, Ph.D., James Madison Professor of Political Economy and Professor of Economics and Public Affairs, Princeton University:
“There is an inconsistency in the US between ethics and policy. We are divided about healthcare being a right yet we impose laws like EMTALA that enforce the ethos of healthcare as a right. We badmouth “socialized medicine” yet the care we offer veterans is just that and we tout it as some of our best work. To be ethically consistent you must regulate risk pooling by including everyone in a social plan and you must mandate it. It seems there is a loss of faith in the private sector, as even large seemingly sound corporations have gone under, so Americans may see a government plan as stable and permanent. “

Bill Vaughan, Senior Policy Analyst, Consumer Union:
“After analyzing the market from a consumers point of view, it is evident we have dysfunctional for profit insurance system. To be successful, the consumer must have meaningful choices. The industry must define terms like “hospitalization”. To some plans “hospitalization” means insurance kicks in and covers costs that incur after a patient is in the hospital 24 hours dodging a huge chunk of costs. As we know a large proportion of hospitalization cost is spent in the first 24 hours during stabilization/diagnosis. Consumers must be educated on these terms at a 6th grade level in order to make educated decisions. A small number (6-10) of clearly outlined options without small print is necessary for consumers to be able to shop for insurance on a NHE.”

William D. Hobson, Jr., MS, President and CEO, Watts Healthcare Corporation, Los Angeles, CA:
“Watts Healthcare Community Center (interms of financial and health outcomes) successfully manages a high-risk group consisting primarily of 23,000 African Americans and Latinos, 96% of which are 200% below the poverty line. A Public Option, where everyone has the option to buy Medicare, is needed to manage vulnerable patients. Private healthcare is a disincentive for the patient to acquire primary health care and offers poor customer service for the high-risk patient.”

Kenneth L. Sperling, Global Health Management Leader, Hewitt Associates, on behalf of the National Coalition on Benefits:
“If we move away from traditional employer based insurance there is concern that citizens will not have the choice to keep the insurance they presently have. When the value of choice was presented to the panel and the Representatives, universally they raised their hands to acknowledge they affirmed the right to choice and conversely no one spoke up to say they didn’t agree with the consumers right to keep their current healthcare plan. Again he brought up the unsustainable negative effects of cost shifting on private insurance should the public option be offered on the NHE.”

David Borris, Owner, Hell’s Kitchen Catering, Northbrook, Illinois:
“I spend 13% of payroll on healthcare and the cost is unpredictable each year escalating far beyond inflation (up 22% last year). The small group insurance market is not working. There is discrimination for chronic illness and it is a moral hardship that employers should not bear. We need a public option to set the bar for quality options that focuses on quality of life not for profit.”

In closing Congressman Stark asked the question, “What if we cannot provide insurance?” Remarks from the panel were compelling. Unemployed and even employed families will continue to bear the agony of being uninsured with a diagnosis of cancer or a premature baby that will bankrupt them. Parents will wait to receive primary care for their children in the ER, missing the timely opportunity for health and prevention of serious conditions. The committee and panel disagreed on how much of what we deliver in “healthcare” as a right, but unanimously agree that it was the moral right of a person living in a civilized country to have access to basic affordable care. Finding how to make that happen continues to be their goal in these sessions. As policy comes out this year, please stay connected and respond to alerts from the AANA. This policy will greatly impact our future as the consumer and the provider of care.