I started and abandoned more diaries -- dating back to July -- on Health Care Reform than I can count. The fact is, I'm not a good diarist - I tend to ramble. In a matter with a lot of complexity - it's not a 2000 page bill because Congress is trying to stimulate the ink cartridge industry - that's not a good thing.
What's more, a substantial portion of the details won't be known until months - even years - after the bill's passage. Many of the provisions take years to go into effect for more than just political reasons. The bill requires the DOL conduct a number of surveys. Those surveys must then be used by the HHS to write rules requiring coverage above the minimums already explicitly stated in the bill... and that's before we even get into litigation that accompanies most bills.
The fact is, it's too much to take in single bite. Anyone claiming they can boil what this bill means down to a few hundreds words isn't being honest. Any such sweeping measure will have that unfortunate side to it.
After the jump, we'll look at what I think is Myth #1 - INSURANCE PURCHASED VIA THE EXCHANGE WILL/CAN BE "JUNK" INSURANCE
First, let's set the narrow parameters... In some cases, you can't help but touch on them, but I'll restrict this to what insurers are required to provide in any plan... essentially - what are the protections that keep a policy you buy, regardless of subsidies, from being 'junk'.
I'm using the bill text from Opencongress.org here - which to my knowledge, is the only one with 'as amended' text thus far the Senate. I'm going to avoid the House bill because - for one thing, the Senate is actually doing its amending to what was a House bill - but for the most part, because people seemed to be on board with the bill the House passed.
Busting the "junk insurance" myth means we're talking about the bills "Qualification" rules for insurers -- meaning, what standards must a plan meet to qualify under this act.
Title I, Subtitle D, Part I is what establishes this - in 4 sections
Sec. 1301. Qualified health plan defined.
Sec. 1302. Essential health benefits requirements.
Sec. 1303. Special rules.
Sec. 1304. Related definitions.
It's the first 2 -- Secs 1301 and 1302 -- that are the important "junk insurance prevention" provisions.
Sec 1301 is basically describing the 'meta' of plan qualifications. Sec 1301(a)(1) - the basic set of principles - is an "and" section, meaning it has to meet all of the requirements. There's a nod {1301(a)(1)(A)} to the affordability provisions (cost controls) in Sec 1311. There's a set of pretty standard requirements {1301(a)(1)(C)} requiring licensing and a few other provisions. The kicker is 1301(a)(1)(B)...
This requires qualifying plans meet the definition of what the bill calls essential benefits -- in other words, an assurance that the plan offers at least these benefits.
Sooo... what benefits are required to be part of these plans?
The bare minimum the law spells out explicitly are those in Sec 1302(b)(1):
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services, including behavioral health treatment.
(F) Prescription drugs.
(G) Rehabilitative and habilitative services and devices.
(H) Laboratory services.
(I) Preventive and wellness services and chronic disease management.
(J) Pediatric services, including oral and vision care.
So far, so good, right? There's maternity and newborn care - should definitely help with that shameful 29th out of 30 industrial nations in infant mortality. Prescription drug coverage. Hospitalization. Ambulance Services (having once taken an ambulance uninsured, I have a personal affinity for that one).
There's no loophole around these benefits. They must be in there. A President Palin in 2012 or a President Chuck Norris in 2016 cannot appoint an HHS Secretary that can do anything about these - until congress passes another bill explicitly repealing all or some of these, they MUST be present in any plan.
The good news for progressives, though, comes in the very next section - 1302(b)(2)(A):
(A) IN GENERAL- The Secretary shall ensure that the scope of the essential health benefits under paragraph (1) is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary. To inform this determination, the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer plans, and provide a report on such survey to the Secretary.
What this means is that the Department of Labor Secretary must conduct a survey of employer-based plans to see what they cover. In other words - benchmark the insurance the already insured prior to the Exchange becoming effective have. The Health and Human Services Secretary must then use this survey to determine if the coverage in the previous section is "typical" -- is it enough?
The HHS Secretary may then add required benefits -- this is where the regulations, the rule making HHS must do will come into play -- to the list of what makes a plan "Qualified".
The bill sets some explicit minimum coverage. Regulations might well add to that list, pending results of this survey and analysis.
We've heard a lot about loopholes for insurers - I don't know what a good antonym for "loopholes" is, but this provision is such a thing.
Next - we close some loopholes - and here's we sort of touch on another topic, namely "discrimination" - but it's somewhat related here because it prevents these "Essentials" from being used for discriminatory purposes for rates. Section 1302(b)(4) is essentially a long list saying things like:
- You cannot overly weight these benefits
- You cannot use the access of these benefits to determine coverage
- You cannot use these benefits as any sort of means to set rates
- etc
Many of these subsections in particular are likely to have some pretty significant regulations written around them. I think Congress actually did a fairly decent job coming up with ways "benefits" might actually be used a backdoor to create "crap plans"... there's weighting... there are protections for using them as 'loss leaders' (meaning - add benefits as a way to screen out people or avoid certain types of coverage under technicalities). But ultimately - when you want to close loopholes, there's only so much that a law can do... which is why this are is sprinkled with provisions requiring the Secretary to periodically review and report. It's expected to be a "living program".
We then start to get into the cost control provisions - which I think deserves its own topic outside of debunking the "junk insurance" myth... The "Special Rules" are essentially the anti-abortion fanatic's friend- those definitely deserve their own section... and frankly - is the area I think requires some work.
As I said in the intro - there's too much in this bill to do in one shot... so I'm going to leave it at that.