Casper forum will analyze Affordable Care Act

Just the Facts Please

By Barb Rea,
ESPC Health Issues Volunteer

As a member of the Wyoming Health Care Commission and now as a Consumer Representative for the National Association of Insurance Commissioners, I’ve had the opportunity to hear high level presentations and discussions about healthcare reform from people who have devoted their careers to improving the healthcare system for the rest of us. These folks are mighty happy to that we finally have a law in place that addresses the healthcare system as a whole.

Nearly all agree it is not perfect, but gives us a place to start that did not exist before March 23, 2010, the date Congress passed the Affordable Care Act. We'll take an in-depth look at the ACA

While policy makers have known for decades that health reform was essential to the economic stability of the country it has been a long and difficult battle to get healthcare reform to the front burner. It’s hard to keep it there.

Admittedly, there is a lot of information for busy people and citizen legislators to learn, but it’s not impossible and there is a lot at stake. Sometimes I think Wyoming people and especially their policy-makers assume that we are so different from the rest of the country that what happens in Washington, D.C. won’t really change anything we do here. But in this case, we would be missing an opportunity to fix some Wyoming problems.

I have a friend who was told by the State Employees’ health insurance carrier, Great West, that the back surgery her doctor told her she needs is medically unnecessary. I also remember in the paper last year a couple was protesting in front of Blue Cross Blue Shield because the cancer drug that their doctor said the husband needed to keep him alive wasn’t in their formulary.

In both cases, there is no amount of consumer research that could have changed these stories. I’m sure they were never even given a chance to make a choice about what their insurance covered or didn’t cover. No one knows what kind of illness they may get and no one really knows the details of what their policy covers until they need it.

On the other hand, if providers are getting away with performing unnecessary surgeries or prescribing expensive new medicine that works no better than the previous version, we want to know that.

Our system should be more transparent, we should know that our providers are practicing evidence based medicine that works and that insurance will pay for the care we need. But in these cases, the patients and their families are suffering not only from their disease process but unnecessarily from a broken healthcare system.

Will health reform solve these problems and many others? Not without constant attention.

An educated public can:

• help move the discussion from one that polarizes and paralyses to one that solves real problems;
• help policy makers remain focused on the ultimate goal of health reform—security for our friends and neighbors in the form of guaranteed access to high quality affordable healthcare.
  

People shouldn’t have to worry that they will lose their healthcare if they get sick or change jobs. Insurance should work, there shouldn’t be any surprises. It should pay for the right care at the right time and it should protect us from bankruptcy.

September conference offers facts on ACA
Several agencies and organizations have come together as One Health Voice to provide a forum where people can hear directly from policy experts about why we need health reform and learn about what the Affordable Care Act can do to begin to transform our healthcare system.

Please join us on Tuesday, Sept. 13, 2011 in Casper for a one day symposium about healthcare reform and the Affordable Care Act, the new healthcare law.

T.R Reid, best- selling author of “The Healing of America, A Global Quest for Better, Cheaper and Fairer Health Care, will keynote the event.

Policy experts from the U.S. Health and Human Services Department, Consumers Union, the Colorado Center on Law and Policy and from Governor Mead’s office will provide overviews of the law, what role states will play in achieving the results they want and what consumers should expect in a reformed health care system.

The conference is open to everyone.

You can register on line at www.OneHealthVoice.com or contact LRosedahl@pubaffairsco.com.

------------------------------------------------------------------------------------------------------------------------------------
One Health Voice includes the Equality State Policy Center and these allies: AARP, American Cancer Society Cancer Action Network, Children’s Action Alliance, Consumer Advocates:Project Healthcare, Department of Family Services-Adult Protection Services, National Multiple Sclerosis Society, CO-WY Chapter, Wyoming Center for Nursing and Healthcare Partnerships, Wyoming Epilepsy Association, Wyoming Health Care Access Network/PhRMA, Wyoming Hospital Association, Wyoming Primary Care Association.

Insurance companies battle health care reform regs

By Barb Rea

Editor's note: Barb Rea is Wyoming's consumer advocate to the National Association of Insurance Commissioners (NAIC). She is attending the NAIC quarterly meeting in Orlando, Fla. She also is volunteering on behalf of Consumer Advocates: Project Healthcare, a group of Wyoming advocates raising the consumer's voice in health care reform. The NAIC is crafting rules that will guide implementation of the the Affordable Care Act.


Health reform is not going to happen magically. The Affordable Care Act (ACA) established the framework for changing the system and now people are working hard to write the rules and regulations that will make it happen.

When you look at the details and the intent of the law, each piece is designed to move the insurance industry to change the way it does business. In exchange the industry will get more customers.

We are trying to move the insurance industry from making its money off risk selection (providing coverage only to healthy people) to one that competes on providing better value to its customers.

But it won’t be easy. For instance, one of the early reforms scheduled to begin Jan. 1, 2011, requires that insurance companies to spend more of your premium dollar on health care (80% in the individual market and 85% in the group market) and less on profit. This calculation is known as the Medical Loss Ratio.

And the companies have to prove they’re meeting the Medical Loss Ratio requirement. If they don’t reach this ratio, they have to give the money back to consumers in the form of a rebate. The law is requiring public transparency and accountability—new concepts in the insurance world.

The goal of this reform is not so much to get money back from the insurance company but rather to force the companies to price their products correctly.

Over the last 5 months the National Association of Insurance Commissioners (NAIC) has brought together consumer representatives, insurance commissioners and insurance company representatives to craft rules and regulations on the Medical Loss Ratio, as assigned to them through the new federal healthcare law. They have been conferencing sometimes daily to decide what numbers have to be reported and create a way to collect and report this information.

This week at NAIC’s quarterly meeting in Orlando, the final decisions on this topic will be made. As you can expect there has been considerable wrangling, with the industry trying to include as many items as possible in the medical expense side of the equation and as few as possible on the overhead side. The consumers won a good number of those battles but not all.

Now just days before this final vote, the industry is pushing for several last minute changes in the calculation of the Medical Loss Ratio. The changes essentially mean many companies would never have to pay a rebate (or change their pricing).

Here are the changes they seek:

• They want brokers’ commissions excluded from the equation;

• They want companies who sell in several states to be allowed to aggregate their numbers nationally, which would enable them to disguise high profits in one state by combining loss ratios from those states with loss ratios from other states where they may charge lower prices or pay higher health care costs;

• The industry also wants to change the actuarial formula previously adopted by the drafting group for evaluating compliance with the Medical Loss Ratio standard. Known as the “credibility adjustment,” the industry wants a change that favors insurance companies over consumers.

The implications are stunning. The industry can appear to be helping to transform the system but continues to try to get away with as much as possible to maintain “business as usual.” This is how they have made their fortunes and there is no reason to believe they won’t continue to behave that way.

Transparency and oversight are provided for in the ACA. To get this to work, we must be vigilant in monitoring the transformation of the health care system. If we don’t have citizens willing to take this job we are not going to move this to the finish line.

Health reform implementation

Health insurance reform moves to state policy arenas

The passage of health insurance reform certainly has stirred emotions here in Wyoming, where statewide candidates seem to be in a contest to see who can come up with the most frightening descriptions of it to justify their calls for repeal.

We see it as a major victory for Wyoming children and families.

The new law advances the financial security and personal health of Wyoming citizens. It delivers reliable coverage that won't disappear if they get sick or lose a job.

One of the chief advantages of the new law is the intent to cover everyone. The law prohibits insurers from refusing coverage because of pre-existing conditions and it enables families to keep their children on their policies through age 26.

The requirement that insurance companies spend at least 85% of their revenues on the health care of their customers likewise is positive and is representative of the law's intent to bring some sunshine into a system that for too long has been, shall we say, less than transparent. More transparency is critical to controlling costs and improving the quality of care.

Barb Rea, the ESPC's part-time development director, served on the Wyoming Healthcare Commission for several years as an appointee of Gov. Dave Freudenthal. That service and her own studies have given her a broad knowledge of the issues involved in reforming health care. We asked her to represent the ESPC on the National Association of Insurance Commissioners’ consumer liaison committee. The NAIC will be instrumental in designing the rules under which the states will implement the new health insurance reform legislation.

Rea recently attended the NAIC meeting in Denver and offered the following observations:

I have just returned from the spring meeting of the National Association of Insurance Commissioners (NAIC) as one of several new consumer representatives serving on consumer liaison committee. This organization and this committee will play an important role as we begin implementation of health reform legislation.

Wendell Potter, posts an excellent summary of this meeting and the role of the NAIC in the Huffington Post which you can read here.

The short version is that the states will be responsible for much of the work of implementing the new health reform bill. The law requires that many new regulations be written to govern the way health insurers do business. This work will fall to not only to the U.S. Department of Health and Human Services but also to the National Association of Insurance Commissioners (NAIC).

The NAIC exists to help state insurance regulators achieve five primary goals:

• protect the public interest;
• promote competitive markets;
• facilitate the fair and equitable treatment of insurance consumers;
• promote the reliability, solvency and financial solidity of insurance institutions;
• and support and improve the state regulation of insurance.
  

So, the NAIC will play an important role in developing standards that both protect consumers and promote uniformity throughout the industry. Many of these laws, regulations and/or rules developed on the federal level will then be modified and adopted at the state level to give states the authority to enforce them.

There is no time to waste – many need to be in place within the next 6-12 months. So much of our time was spent determining how to ensure that the consumer perspective was going to be represented as the NAIC moves forward.

The NAIC executive committee stated its intention to utilize its existing committees to complete these responsibilities. The role the consumer liaison committee will play is still not clear. The consumer liaison committee specifically asked the NAIC:

1. to create a publicly accessible “plan of action” developed with input from consumer representatives;
2. to fully incorporate consumer advocates into the NAIC health reform work plan;
3. to prioritize their tasks based on the needs of the consumers;
4. and to significantly expand consumer participation at the NAIC proceedings.
   

While we await a response from the governing board of the NAIC, the consumer liaison committee will begin immediately to assess our resources and organize into work groups around the most urgent issues:

• High risk pools;
• Grants for establishing ombudsmen offices to assist consumers in every state;
• Medical Loss Ratio (MLR);
• Rate reviews;
• New insurance policy requirements (e.g.) pre existing conditions, keeping young adults on parent policies, first dollar coverage for prevention.
  

Next steps for Wyoming and the ESPC
It was humbling to be among such knowledgeable and effective colleagues, many of whom have been working on reform for most of their careers. We certainly have a lot to gain as this process will provide both context and product for much of the decision-making that will fall to our legislature. It should make their job easier.

But, it soon became clear to me that the process of implementing anything at a state level here (or in any other state already fighting the intent of this law) was going to be more complicated than cutting and pasting good ideas into Wyoming law. Our first task will be to cut through the rhetoric and talk about how the new law addresses the health care access problems people are facing.