Health Care Reform Debate: More Thought and Less Volume, Please

By Erika Stewart

Health care reform will make huge changes in the way insurance companies do business, but most of that will not go into effect right away. Provisions that will help most Americans in 2012 affect policies that were purchased after March 13, 2010.

Under the new laws, health insurance companies cannot:

• Refuse to cover children under age 19 who have a pre-existing condition
• Impose a lifetime limit
• Cancel a policy unless they can prove fraudulent information was given
• Fail to provide an appeal process for denied claims

New insurance policies must now include reasonable preventive services that carry no copayment or deductible. This includes usual vaccinations, cancer screenings, well-child office visits, blood pressure checks, and tests for such chronic conditions as diabetes and high cholesterol.

Children without insurance who have not reached the age of 26 can now be carried on their parents’ insurance, even if they are married and no longer live with their parents.

Newer health plans must allow the patient to choose a primary care physician and cannot require a referral for an OB/GYN service. The law also prohibits companies from requiring patients to go to a particular emergency room or get prior authorization for emergency care.

Effects on Physicians

While all this is good news for American families, what about the effect on doctors? Why was the bill endorsed by both the American Medical Association and the American Hospital Association?

Primary care physicians will receive more pay from government-sponsored insurance such as Medicare for encouraging patients to take advantage of preventive and outpatient services likely to lower the overall cost of care for individuals. They will also receive incentives for providing coordinated care, and for using electronic health records so that patients are better understood.

Hospitals will benefit from reducing the number of charity cases without any payment. By 2014 Americans will receive subsidies to help those with lower income afford medical insurance.

Starting in 2014, Medicaid will cover most people who have less than 133 percent of poverty level income. This is projected to bring an additional 16 million people into that system. The impact on states will vary, depending on how generous the Medicaid program is there. The Federal government will cover the cost until 2020 but will then ask states to shoulder more of the burden.

With many politicians eyeing cuts to Medicaid in order to bring the budget under control, the poorest of American citizens may be in jeopardy of losing some of their medical care. President Obama has promised to cut $100 billion. House Republicans, led by Paul Ryan, are pushing to change Medicaid to a block grant program and repeal the expansion of coverage.

Sustainable Growth Rate (SGR)

Another interesting aspect of our health care law is Medicare’s Sustainable Growth Rate (SGR). SGR is defined as the fastest rate at which an organization can grow without collapsing. This figure is used to adjust the Medicare fee schedule so that the fund does not become depleted. If expenditures exceed the SGR, the fee schedule is adjusted downward. However, the formula used does not take into account the increasing volume and complexity of care. A true reflection of program costs must take these factors into consideration.

Some critics have complained that the health care reform law does not address this issue. That was not the focus of the bill, which deals mainly with issues of insurance coverage. As the debate about health care reform continues, doctors have weighed in both in favor of the law and concerned about its implications. On her blog “Barking Doc,” Maggie Kozel MD presents her perspective. She says, among other astute comments, that the discussion needs to focus on stewardship. As citizens of this wealthy nation, what is our responsibility?

Dr. Kozel is author of “The Color of the Atmosphere: One Doctor’s Journey In and Out of Medicine.” After 10 year’s of practice in Navy medicine, Kozel entered private practice where she was confronted with the inequities of the current system and what that means in terms of patient care. Speaking of the relationship between doctor and patient, she writes, “conversation between doctor and patient is the most undervalued commodity in our health insurance system.”

Whether the new law will survive attacks by conservatives, and how well it will address the needed changes in our health care system, remain to be seen. Thoughtful debate on the serious issues involved instead of bickering backed by special interests would help both Congress and the President focus on positive change. As Dr. Kozel writes, what is needed is more thought and less volume.