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This Week in Health Care Reform     

Health care reform legislation passed the House this week on a party-line vote. Late Sunday night, House Democrats approved the Senate health care reform package, sending the legislation to President Obama for his signature. On Tuesday, President Obama signed the underlying bill into law, yet the House has yet to finalize the package of “fixes” that will alter the final implications of the legislation.

Health Care Reform Negotiations

House Democrats Pass Health Care Reform Package: The House of Representatives approved the Senate health care reform bill Sunday night by a vote of 219 to 212. The vote marks the climactic finale to a year-long debate over health care reform. In the final vote, 34 Democrats joined all House Republicans in voting against the measure. Shortly thereafter, the House also passed a package of “fixes,” by a vote of 220-211, that was sent directly to the Senate for its approval through reconciliation. On Tuesday, President Obama signed into law the Senate health care reform bill, called the “Patient Protection and Affordable Care Act.”

Republicans Force Senate to Send the Reconciliation Bill Back to the House: Shortly after the President signed the Senate bill into law, Senators began deliberations on the reconciliation bill. Reconciliation protocol restricts Senators to 20 hours of debate on the measure, but it does not limit the number of amendments that can be filed. In an expression of opposition to the bill, Republicans filed 29 amendments to the reconciliation package.

After 10 hours of continuous debate, Republicans were successful in eliminating two provisions related to college financial aid in the non-health care portion of the bill. The Senate parliamentarian ruled early Thursday morning that those two provisions violated the chamber’s rules, sending the legislation back to the House for a new vote. As a result, on Thursday afternoon, the Senate voted on the reconciliation bill without those two provisions and sent the bill  back to the House for a vote on final passage. The House vote will likely come Thursday evening.

What Does This Health Care Reform Legislation Mean: While the health care reform bill extends insurance coverage to 32 million more Americans by 2019, the legislation has other far-reaching implications that will be phased in sooner, during a multi-year implementation period.

Several features of the new health care overhaul bill that would take effect in 2010 under the measure passed Sunday include:

* New product requirements beginning 6 months after enactment, including:
o Coverage for dependents up to age 26
o No lifetime maximum benefit limits
o And no cost sharing on preventive care for certain policyholders
* Temporary federal high risk pools;
* Tax credits for small employers; and
* Prohibition on pre-existing condition exclusions for children (beginning 6 months after enactment).

Most Americans will have until 2014 to purchase insurance or pay a penalty. Other elements of the bill that will not take effect until at least 2014 include insurance marketplaces called “exchanges”; rules requiring insurers to accept all applicants regardless of pre-existing conditions, and an expansion of state Medicaid programs.

A number of experts question whether health care reform will really drive down insurance premiums. America’s Health Insurance Plans ( AHIP), the trade group representing health insurers, outlines a series of concerns related to the legislation including a lack of provisions that address underlying health care costs, improve quality of care or ensure a stable risk pool. In addition, AHIP expressed concerns regarding new taxes on health coverage, which will likely increase premiums.

Additional Activities

Obama’s Executive Order on Abortion Funding: On Sunday afternoon, prior to the final House vote on health care reform, President Obama agreed to issue an Executive Order that would uphold the ban on federal funding for abortion . In so doing, he secured about a half-dozen votes from anti-abortion Democrats, led by Rep. Bart Stupak (D-MI), who previously opposed the legislation. On Wednesday, President Obama signed the Executive Order banning the government from spending federal money to pay for abortions through plans offered on the insurance exchanges created under the measure.

States Filing Lawsuit to Fight Provision of Health Care Reform Bill: In response to the new health care reform legislation, states across the country have filed lawsuits asking the courts to declare the law unconstitutional and to bar its enforcement. On Monday,Attorneys General in 13 states, led by Florida, filed a joint lawsuit claiming that the new health care reforms violate state government rights in the U.S. Constitution and will force massive new spending on hard-pressed state governments. Joining Florida in the suit are Alabama, Colorado, Idaho, Louisiana, Michigan, Nebraska, Pennsylvania, South Carolina, South Dakota, Texas, Utah and Washington.

At the same time, the Attorney General in Virginia filed a separate suit contending that Congress has exceeded its power in mandating that people buy health insurance. Virginia Attorney General Ken Cuccinelli argues that the new law’s requirement clashes with Virginia law that exempts citizens from federal fines imposed for not having health insurance.

Senate Voting to Extend COBRA Until May 5:  Senate Democrats plan another short-term extension of unemployment aid this week, setting up a face-off with Republicans, who are vowing to fight the extension if the $10 billion cost isn’t offset with spending cuts. The bill, currently set to expire on April 5, would extend a series of emergency programs – including funding for unemployment insurance benefits and COBRA health coverage for the jobless  – and would hold off a deep cut in reimbursement rates for doctors who serve Medicare patients. The long-term extension has already passed in both the House and Senate, but the two measures are not expected to be reconciled and sent to the President’s desk until after the Easter recess.

President Obama Heads to Iowa to Speak on Health Care: President Obama headed to Iowa on Thursday to increase support for his health care legislation. This was President Obama’sfirst trip out ofWashington since signing health care reform legislation earlier this week. He spoke at the University of Iowa, in the city where he first announced his health care proposal during the Presidential campaign.

Public Opinion

Most Americans Want Republicans to Fight Health Care Reform Bill: In a recent CBS News poll, 62 percent of Americans said they want congressional Republicans to continue challenging the bill, while 33 percent said they should not. Disapproval of the bill has remained steady, with 46 percent saying they disapprove, including 32 percent who “strongly” disapprove. A majority of Americans continue to say that they find the bill to be confusing and do not understand what it means for them or their family.

American’s Split on Health Care Reform Passage: In a recent USA Today/Gallup poll, 42 percent of Americans said they were angry or disappointed with the recent passage of health care reform legislation. When asked to reveal party affiliation, 79 percent identified themselves as Republicans.

Polling Shows Support for State Lawsuits Against Government: National polling reveals significant opposition to the individual mandate. In a newly released Rasmussen report , 53 percent of those polled oppose the new mandate requiring every American to buy or obtain health insurance. Further, 49 percent of voters are in favor of their state suing the federal government to fight the mandate. Fifty-one percent say individual states should have the right to opt out of the health care plan entirely.

Looking Ahead

After this week’s final health care reform vote, President Obama plans to travel the country in the next few months to discuss the new law. Republicans have begun their own discussions of the law, with an eye towards the November elections.

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President Obama Releases New Health Care Proposal in Time for Health Summit: On Monday February 22, 2010, White House officials unveiled a new health insurance reform overhaul that builds on the Senate version passed last Christmas Eve, with some changes aimed at pleasing House Democrats who had concerns with the Senate bill. The President’s proposal does not include the public option, despite the hopes of Senate Democrats, due to White House concerns that the provision will hinder passage in the Senate. President Obama ignored requests by Republicans to scratch the Democratic plan and start over. As such, Republican leaders questioned Democratic motives and labeled the bill as a massive government takeover of America’s health care system.

Republicans Insist House Democrats Don’t Have the Votes to Pass Legislation: Minority Whip Eric Cantor (R-VA) announced on Wednesday that Democrats don’t have the necessary votes to pass the President’s proposal in the House because of three new House vacancies and lagging support among some moderate Democrats. At issue for some Democrats are weaker abortion provisions in the President’s proposal as well as the ongoing controversy over passing a bill by a simple majority, a process known as reconciliation.

Health Care Summit Preview

On Thursday, the President’s Health Care Summit began at 10:00 a.m. with opening comments from the President, followed by remarks from both Republicans and Democrats. The discussion centered on four themes: controlling health care costs, overhauling the insurance market, reducing the deficit and expanding insurance coverage. Prior to Thursday, several top Republicans and some Democrats stated that expectations were extremely low for the Summit’s success.

House Republicans arrived armed with their own version of a health care bill that encourages small businesses to join together to buy insurance, gives federal money to states to run high-risk pools for those unable to obtain private insurance and limits damages in medical malpractice lawsuits. The Republican plan would cost $61 billion and cover three million people over ten years. In contrast, President Obama contends his plan would cost $950 billion and cover 30 million people over the same time period. However, officials at the Congressional Budget Office (CBO) indicated they would not be able to officially score the President’s proposal with just a summary – that legislative language is needed.

Note: A full summary of the results from the Health Care Summit will be included in next week’s newsletter

Additional Activities

WellPoint Executives Defend Premium Increases: On Wednesday, the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing to examine the proposed health insurance premium increases by Anthem Blue Cross in California. Anthem, a WellPoint subsidiary, recently informed subscribers in California that premiums for individual insurance policies would be raised an average of 25 percent, with some rates going up as much as 39 percent. Angela Braly, president of WellPoint , said the premium increases were justified by soaring medical costs, and that pending legislation could make the problem worse, driving up costs further for young, healthy people.

“Raising our premiums was not something we wanted to do,” Ms. Braly said . “But we believe this was the most prudent choice, given the rising cost of care and the problems caused by many younger and healthier policyholders dropping or reducing their coverage during tough economic times. By law, premiums must be reasonable in relationship to benefits provided, which means they need to reflect the known and anticipated costs they will cover.”

In Sacramento , Leslie Margolin, president of Anthem Blue Cross in California, also testified before lawmakers, joined by vice president and general manager James Oatman. The focus of that hearing was also the proposed premium increase for California members in the individual market, with company executives pointing to the current economic climate and rising health care costs as reasons for the rate hikes.

U.S. House of Representatives Repeals Antitrust Exemption from Health Insurance Companies: On Wednesday, the House of Representatives voted 406-19 in favor of repealing a 65-year-old antitrust exemption from health insurance companies. Democrats said the repeal would lead to increased scrutiny of the industry. Yet, the non-partisan Congressional Budget Office said last year that repealing the exemption would not significantly reduce premiums because states already investigate health insurance companies.

In addition, industry executives pointed out that legislation could further hinder competition and the ability to share information to improve health care quality. “Health insurance is one of the most regulated industries in America at both the federal and the state levels,” said Karen Ignani, president and chief executive of America’s Health Insurance Plans (AHIP). “The real focus should be on addressing the rising cost of medical care, which is putting an unsustainable burden on families, employers and the federal budget,” she said.

Public Opinion

Polling Suggest Health Care Reform is Still Key to Economic Recovery: Recent polling on health care reform shows mixed reaction among the public over the proposed legislation. According to a recent CNN poll, 48 percent of those questioned said lawmakers should work on an entirely new bill and 25 percent felt that Congress should stop work on health care reform altogether.

According to the monthly poll from the nonpartisan Robert Wood Johnson Foundation, 75 percent of Americans still think it’s important that Obama include health care reform in addressing the nation’s economic crisis, while many still harbor doubts about the legislation.

When asked how health care legislation relates to their economic situation:

* Nearly 31 percent said they thought the Democratic bills would make their personal financial situation worse, compared with 10 percent who said it would improve their family budgets.
* Forty-two percent said the nation’s fiscal condition would suffer because of the legislation, compared with 26 percent who said it would get better.
* Americans were divided on whether the Democrats’ approach would improve overall access to health care around the country, with 35 percent saying it would and nearly that many disagreeing.

Health Insurance Coverage Varies Widely Based on Age: Coming just before the President’s Summit on Health Care Reform, a newly released Gallup Poll reinforces the wide degree of variability in health insurance coverage across U.S. population segments, especially when it comes to age. Eighty-four percent of 18-year-olds have health insurance, most likely because they are still covered under their parents’ policies. By age 22, health insurance coverage reaches its lowest point, with just 66 percent maintaining coverage. From age 22 on, the percentage of Americans with health insurance begins to climb, albeit slowly, reaching the 95 percent level at age 65 when Medicare becomes an option.

Looking Ahead

Legislators need to determine next steps for health care legislation coming out of the President’s Health Care Reform Summit. On Wednesday, Department of Health and Human Services Secretary Kathleen Sebelius invited executives from the top five insurance companies to meet at HHS to discuss their companies’ insurance premiums.

Owing to multiple blizzards in Washington, Congress started its President’s Day recess a full week early and conducted no official business last week. However, there was some legislative drama as Senate Majority Leader Harry Reid pulled the rug out from under Finance Committee Chairman Max Baucus by scrapping the Baucus jobs bill (without warning), which contained many health insurance items, and replacing it with a stripped down, narrow jobs bill. Whether the health items Baucus originally inserted with Republican help will make it back to the table remains fuzzy. Among the health items that have been dropped are: the COBRA eligibility extension (to May 31); the “doc fix” (to October, 2010) of Medicare reimbursement rates; and the favorable statutory direction to CMS to calculate the 2011 Medicare Advantage rates “as if” the doc fix were in place.

States

California health insurance The Office of Patient Advocacy released a report card on the state’s HMOs last week. Aetna received 3 out of 4 stars. The goal of the report card is to allow consumers to compare how well health plans use personal medical records and help address conditions such as asthma, arthritis and diabetes.

COLORADO: Governor Bill Ritter held a press conference to announce what he calls “the next round of reforms that represent common sense.” His legislative package includes bills to preclude insurance companies from charging different rates due to a person’s gender, ensure that women have access to breast cancer screening, assure plain language is used in insurance forms, standardize insurance applications and explanations of benefits, and encourage greater use of online tools to enroll people in public programs. Apart from the Governor’s proposals, a bill that would establish a public option was also introduced.

CONNECTICUT: In a short legislative session of only three months, the Insurance & Real Estate Committee wasted no time in putting forth an agenda that includes many concept drafts for repeat legislation from previous sessions. These include prohibiting health insurance copayments for preventive care, limiting prescription drug copayments, prohibiting Social Security disability payment offsets, and exempting the Municipal Employees Health Insurance Plans from the premium tax on small group premiums. In addition, the committee reintroduced legislation that includes nearly a dozen new health benefit mandates. The Council for Affordable Health Insurance, an independent think-tank, says that health insurance mandates could increase premiums in Connecticut by more than 50 percent overall.

GEORGIA: A bill was proposed last week that would impose significant restrictions on insurers’ ability to rescind health insurance policies. Aetna, through the Georgia Association of Health Plans and AHIP, met with the legislator sponsoring the bill to express concerns with the bill.

INDIANA: The legislative session is at halftime, and the insurance agenda is now limited. Most insurance issue bills are officially dead, including a bill that would have prohibited health plan provisions requiring a contracted provider to accept more than a certain number of patients; coverage for dialysis treatment regardless of whether the facility is contracted or not and without certain benefit restrictions; and a bill that would have allowed out-of-network assignment of benefits. However, Aetna is expecting that a bill requiring insurer and HMO annual reporting of premium cost composition, including administrative costs, may be resurrected. A bill that restricts dental insurers and HMOs from establishing fee schedules for non-covered services passed the Senate, with our amendment to accommodate most of the key concerns expressed by opponents of the bill. As the bill stands, dental insurance plans may impose fee schedules for covered services, regardless of whether the plan actually pays for the services rendered.

KANSAS: An amended version of S.B. 389 related to dental services passed the Senate Financial Institutions and Insurance Committee on February 11. The amended bill prohibits any contract between a health insurer that offers a health benefit plan and a dentist from containing a provision that requires the dentist to accept a fee schedule for services unless the service is a covered service. Committee amendments added to the definition of a “health benefit plan” the following: any subscription agreement issued by a non-profit dental service corporation; any policy of health insurance purchased by an individual; the state children’s health insurance plan; and the state medical assistance program under Medicaid. We will continue to update you as this bill progresses and hope to make favorable changes as the bill moves through the House.

MASSACHUSETTS: Governor Deval Patrick filed a 40-page bill that proposes giving the insurance commissioner the power to hold public hearings on rate adjustments and essentially cap health care price increases. Rate increases for individuals would be held to the rate of medical inflation; those sold to employers with 50 or fewer workers could not exceed one and a half times the level of medical inflation. The legislation would also impose a two-year moratorium on any new health benefit mandates. Legislative leaders praised the intent of the governor’s plan but declined to promise support. Strong opposition is expected from medical provider groups. The Governor simultaneously announced emergency regulations to take immediate effect that will require health insurers to submit proposed small business rate increases for review by the state 30 days before they take effect. Several other proposed provisions include a requirement that insurers offer at least one coverage plan with a limited network of health care providers costing at least 10 percent less than health plans with access to more physicians. The Massachusetts Association of Health plans is lobbying in support of a bill introduced by Senate Insurance Chair Richard Moore that would create a cheaper health insurance product for small employers by capping payments to providers at just 10 percent above Medicare rates. The Massachusetts Medical Society is against that proposal.

MISSOURI: An autism coverage mandate bill was amended and “perfected” by the Senate and then sent to the Government Accountability and Fiscal Oversight Committee from which it must emerge before returning to the floor of the Senate. In addition to two mandate-related amendments, a third amendment to the bill allowing for limited cross border sales of health insurance also passed. In its current form, the bill contains a mandated offering of the coverage in the individual market. Coverage is limited to treatment ordered by a licensed physician or psychologist whose treatment plan the carrier is entitled to review every six months. Coverage for applied behavior analysis (ABA) is limited to $52,000 annually (down from the $72,000 as introduced) for persons under age 21. Meanwhile in the House, a bill containing significant language relating to the credentialing of autism service providers also passed. The bill also contains a mandate to offer coverage in the individual market and to groups of fewer than 25. Groups of 25 to 50 would be entitled to an exemption from the mandate if they could demonstrate an increase in premiums tied to the mandate. The bill limits annual coverage of ABA ($36,000 for children ages 3-9; $20,000 for children ages 9-21). Aetna will continue to monitor the status of these mandates, but it appears fairly clear at this point that something will pass on the issue of autism.

NEW JERSEY: Last week Governor Chris Christie declared a fiscal state of emergency calling a special session of the legislature to lay out his plan for dealing with state’s current $2.2 billion budget shortfall. His plan calls for significant cuts or eliminations across 375 state programs and withholding $500 million of state education aid. Of note on the program side is a $12.6 million reduction in Charity Care funding to hospitals, which pays for care to uninsured residents. In legislative action, the Assembly Financial Institutions and Insurance Committee held a three-hour public hearing on out-of-network reimbursement. Much of the hearing focused on the markedly higher billing practices of ambulatory surgery centers and one non-par hospital. Aetna presented testimony regarding its experience with the non-par hospital, citing their disparate year-over-year increase in charges compared to other similarly situated hospitals. Chairman Schaer indicated the committee will work over the next several months to craft a solution.

NEW YORK: With Democratic Senator Hiram Monserrate officially expelled from the Senate, the Democratic majority (31-30) now faces an uphill battle getting the 32 votes needed to pass legislation. However, both the Senate and the Assembly moved forward with a public hearing on the Executive Budget proposal for health, including the section mandating the prior approval of rate adjustments. The Health Plan Association testified on behalf of the industry. If enacted, Governor Paterson’s proposal for an 85 percent medical loss ratio and a prior approval hearing process for all rate adjustments would essentially amount to government control of health insurance, undermining the private health insurance market in New York. Price controls would weaken health plan solvency, hurt providers and virtually eliminate innovation and efficiency. At the same time, the proposal ignores the underlying cause of the increasing cost of health insurance — the increase in the actual costs of health care services.

OKLAHOMA: The second session of the 52nd Oklahoma Legislature convened in Oklahoma City on February 1. Legislators quickly turned to the state’s $1.3 billion budget deficit described by Governor Brad Henry (D) in his eighth and final state of the state address and FY 2011 executive budget. During his address, the Governor focused on his plans for resolving the $1.3 billion budget deficit through precise budget cuts. His only reference to health insurance was to encourage the expansion of Insure Oklahoma, a program developed by the state in partnership with small employers to provide affordable health coverage. The legislature is scheduled to adjourn on May 28 but only after addressing a range of legislation including several bills of interest to Aetna.

SOUTH DAKOTA: A dental fee schedule bill (S.B. 108) unanimously passed the Senate Commerce Committee and is expected to be taken up by the full Senate early this week. The bill prohibits any contract between a health insurer that offers a health benefit plan and a dentist from containing a provision that requires the dentist to accept a fee schedule for services unless the service is a covered service. Aetna will continue to follow the bill’s progress as it progresses.

TENNESSEE: Several bills have been proposed that would make changes to the state’s external review law. Aetna and other industry representatives will be meeting with the Tennessee Department of Commerce and Insurance regarding its proposed changes to the external review law. The bill proposed by the TDCI most closely mirrors the model legislation proposed by the National Association of Insurance Commissioners.

UTAH: The Speaker of the House has introduced a health reform bill addressing health information technology, individual and small group market reforms and transparency. The overarching theme of the reforms is micromanagement of rates and rating factors, and a broadening of the Insurance Commissioner’s authority. The transparency provisions apply plan designs and benefit descriptions submitted by carriers, and would require providers to make available, upon request, a price list for services on both an inpatient and outpatient basis.

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