Health Care Reform. Who knew those three little words could evoke so much interest, emotion, and confusion all at once? Health care reform is arguably the most divisive issue to hit Washington in decades, and the entire country has responded with strong opinions in both directions. What does the proposal really mean for the average American family? It seems the answer to that is about as clear as mud, if you’ll pardon the cliché. When I decided to take on this project, I attended health care forums, read everything I could get my hands on that seemed to be from a reputable, bipartisan source, and asked for thoughts and concerns from local families. The information was overwhelming, even for a girl who tends to follow politics… and while I couldn’t begin to present everything I learned, I can highlight some of the main ideas and point out a few misconceptions.

Health Insurance in the United States
Most Americans agree that the current health care system in America needs to be reformed. Overall, the U.S. spends more on health care than any other country in the world, yet ranks behind 18 other industrialized nations in medically preventable deaths. Clearly, there is a major disparity in the amount of money being spent and the quality of care being provided. What no one seems to be able to agree on is how best to bridge that gap. The sheer complexity of the proposed bill, HR 3200 has left many Americans scratching their heads in frustration, and even a particularly eloquent President can’t seem to fully explain its implications for the average American family. Further, both sides of the aisle are using that confusion to create propaganda which has been at times misleading.

So what do we know? Approximately 15% of Americans are without health insurance coverage of any kind. That adds up to roughly 46 million people, though this number, too, has been met with debate. Many of those who find themselves in this population fall above poverty level and do not qualify for public programs. They may be self-employed or work for a small company that does not provide insurance benefits to its employees. Private insurance is costprohibitive for many middle-class Americans, and families find that coverage simply isn’t in their budget. Research shows that people who lack health insurance coverage typically put off basic medical
care, and often end up in emergency rooms when they become ill. As a result of having reduced care, this population is statistically less healthy and more likely to develop chronic diseases, the cost of which is absorbed by taxpayers.

Of those with health insurance, approximately 53% are covered through an employer group plan. These plans are tax-free, and many employers pay a significant percentage of the premium as part of an employee’s compensation package. Larger groups get lower premiums, and providing insurance in a small company is often not financially feasible. Furthermore, workers cannot take insurance with them if they are laid off or switch jobs, which often leads to a gap in coverage.

Approximately 26% of Americans are covered by public programs such as Medicaid and/or Medicare. Medicaid
is a state-run program for low-income individuals and families, but many states are already struggling to meet costs. In addition, low reimbursement rates cause many providers to reject Medicaid patients, or to accept a limited number. Medicare is the federally-funded medical plan for Americans aged 65 and older, which was established in 1965 during Lyndon B. Johnson’s presidency. Baby boomers are creeping up on 65, and may soon stress the Medicare system, and many seniors already face major gaps in prescription drug coverage. The remaining 5% of insured Americans rely on independent plans they’ve purchased on the open market. This group typically pays the highest premiums, as they are not in a large risk pool and are evaluated based on their health profile. Coverage choices are often limited, and these plans typically are purchased with aftertax dollars.

Understanding HR 3200 and S. 1679

President Obama won the Oval Office after making some lofty campaign promises, and health care reform was squarely at the forefront. In July of 2009, HR 3200 was formally introduced in the House, titled “America’s Affordable Health Choices Act of 2009.” Immediately it ignited a long-brewing firestorm, with conservatives making claims about Socialism and liberals keeping details vague and sugar-coating the cost analysis. The bill itself is, of course, available for review on the Library of Congress website—all 1,017 pages of it. The question, then, is what exactly is in there? And what isn’t?

Officially, HR 3200 in its original form sets forth provisions governing health insurance plans and issuers. Among them, it seeks to prevent preexisting condition exclusions, provide for guaranteed coverage of all individuals and employers, and requires automatic renewal of coverage. HR 3200 would require qualified health benefits plans to provide essential benefits, and prohibits an essential benefits package from imposing any annual or lifetime coverage limits. Furthermore, it lists the services that would require coverage, including hospitalization, prescription drugs, mental health services, preventive services, maternity care, and children’s dental, vision, and hearing services and equipment. The bill seeks to limit annual out-of-pocket expenses to $5,000 for individuals and $10,000 for families.

HR 3200 would establish a Health Choices Administration as an independent agency to be headed by a Health Choices Commissioner. Within the agency, a Health Insurance Exchange would be created in order to provide individuals and employers access to health care choices, including a public insurance option. HR 3200 would require employers to provide coverage to employees and make specified contributions toward that coverage, and those who failed to do so would face a tax penalty. Likewise, individuals who opt not to obtain coverage for any reason would also face a tax penalty. In addition, the bill seeks to impose a surtax on individual adjusted gross incomes exceeding $350,000. The bill would also amend current Medicaid regulations by expanding eligibility, requiring coverage of more preventive services, and increasing payments for primary care services.

Okay, so is that all? Well, no…it’s not even close, but those are the main ideas of the bill as it is outlined on the Library of Congress website. In mid-September, the Senate introduced a related bill labeled S. 1679. It is very similar to HR 3200, but not identical. Still in its early stages, there was very little official information available on its exact contents or how it differs from HR 3200. Indeed, the discussion in Washington is changing daily, and new information is constantly becoming available.

In Other Words…
What exactly does all of that mean for average Americans? For uninsured Americans, expansion of the Medicaid program could cover large ranks of those currently without coverage. Those who are forgoing insurance because of the cost may qualify for a federal subsidy which would assist them in purchasing private insurance or buying into a public-insurance plan. On the downside, while the gap would become much smaller, the plan may still leave some in a lurch. If the government requires individuals to have health insurance, but doesn’t require employers to provide it, the working uninsured would still have to shop for insurance on their own. Some individuals will likely still be too poor to purchase insurance, but not poor enough to qualify for Medicaid or a federal subsidy.

For those who currently have employer-sponsored health care, it means that more regulation would reduce the chances of insurers denying fair claims. A public plan would introduce competition in the marketplace and might bring down private insurers’ premiums. On the flip side, lawmakers are considering taxing some of the most expensive employee health plans, possibly by taxing the insurance companies directly. Insurers are likely just to pass this cost along to consumers, which could drive up the rates.

Those who are currently insured independently are likely to see the most benefit from the proposed bill. A public option is likely to be available for individuals from the start, and new regulations would prevent insurers from setting rates based on health status and pre-existing conditions. Federal subsidies could play a part in reducing the burden on lower-income earners that fall into this category.

For those who are insured under one of the current public programs, more focus on prevention, lifestyle, and management of chronic diseases could lower costs overall, insuring the program’s long-term stability and improving quality of life for the insured as well. However, lawmakers say that while increased efficiency and preventive care could bring down Medicare spending, they may have to reduce coverage as well. In addition, broadening eligibility criteria for Medicaid would significantly increase federal spending.

Of course, there are other points of controversy. In fact, many entire articles could be (and some have been) dedicated to investigating some of the more sensational claims, such as cancer care rationing and death panels. While these claims are based on some very real fears, the bill itself indicates that most of the claims are unfounded, or at least point to highly unlikely scenarios.

Local Viewpoints
An Edmond resident and mother of two, Sundy Corbin is a licensed insurance agent, and is a District Manager for HealthMarkets. She manages a local branch for the company, and oversees sales, training and compliance for agents in Oklahoma. She also sits on a number of advisory boards and is involved in product development for the industry. She has been watching the health care reform dialogue very closely.

When asked about her concerns, Corbin noted that the discussion seems to have shifted from health care reform to health insurance reform. “A lot of reform still needs to occur at the provider level. Care needs to be more streamlined, more efficient. I feel like providers need to address lifestyle and preventive care to reduce costs.”

While Corbin has faith that the administration can make the health care reform bill work, she admits that she wonders how it will translate into something affordable for families. “They need to show us exactly how they plan to make this work.” Corbin acknowledges that there is room for improvement at the insurance level. “For the first time in my career as an agent, I won’t have to tell someone they can’t get insurance because of their health. This is a moral issue to me, something that should be a basic human right. Could you imagine not having Medicare?”

Lindsey Koch is an RN at Oklahoma Heart Hospital, and is expecting her first child. She stays current on what
is happening with the health care reform debate, and feels that it directly impacts her career and family. “HR 3200 is not socialized medicine. People who have private insurance can choose to keep insurance or those who wish to change coverage,” she notes. “Many of our health care costs exist because those who have insurance pay for those without in the end. Everyone ought to receive the same quality of care in this country, not simply those who
can afford it.”

Koch also likes that HR 3200 stresses the importance of preventive care. “I would guess that many of the patients I see put off important check-ups because of the cost. Doctors can easily treat most hypertension, diabetes, and cholesterol issues if detected early. Some people don’t realize their cholesterol is 320 until they have a heart
attack and end up at the hospital.”

Edmond pharmacist Dave Mason is far more skeptical. “The government has not yet shown me that it can run this type of program well. Medicare and the VA aren’t exactly models of effectiveness or efficiency. I really can’t see how this can be accomplished without some kind of rationing taking place.” In addition, as a small business owner, Mason is not fond of the idea of being required to provide insurance coverage to his employees, although he has done so for years. “I’ve been blessed to be able to supply it, but I know that can be a tremendous financial burden on a business, even in a healthy economy. That money has to come from somewhere, and cuts in overhead could
ultimately lead to a higher unemployment rate. Nobody wants that.”

Health care reform is a complicated and emotionally-charged issue, and the details continue to unfold. President Obama has vowed to have a revised bill signed into law before the year’s end, and lawmakers have a tough road ahead as they continue to negotiate the details of HR 3200 and S. 1679. For information about the bills, visit the Library of Congress website.

Shannon Fields is a freelance writer and a Certified Pharmacy Technician at Innovative Pharmacy Solutions.