One of the issues that Amnesty International addressed was postpartum care.  More than half of all pregnancy-related maternal deaths occur in the six weeks following birth, and yet most women aren’t seen for a postpartum checkup until the end of that time period.  The midwife we worked with for our son’s birth provided prenatal checkups at her office during the pregnancy, but once our son was born, she came to us for postpartum checkups.  We had six postpartum checkups in the first eight weeks following the birth, and for four of those visits, she came to our house.  The first postpartum visit was two days after our son was born.  We didn’t have to leave the house to take our son for checkups until he was over a month old.

The $3,000 that our midwife charged was quite a bargain, given all the service she provided.  If there had been a complication that required surgery or emergency intervention, she would have had to refer us to a hospital, but at least the problem would have stood a better chance of being caught than if I hadn’t had any postpartum care at all for six weeks after our son was born.  But in order to get that level of care, we had to pay for it ourselves (most individual health insurance policies in Colorado don’t cover maternity care, and the ones that do offer maternity don’t cover homebirths) and seek out a midwife outside of the traditional American maternity care model.

The Amnesty International report should be an eye-opener for a lot of people.  We spend a vast amount of money in this country on maternity care, and yet our results are quite poor compared with other developed countries.  Hopefully it won’t take two more decades to get back to the level of maternal death rates that we had in the 80s.

I don’t know any more details about Mr. Abbate’s specific situation than what was included in the article about the rally.  I don’t know if he has chosen to carry a private Medigap policy or Medicare D for prescriptions.  But I wonder if he’s aware of just how much a private health insurance policy would cost if such a thing were available.

Individual health insurance is available until a person reaches age 65, but the prices increase dramatically with age; people in their 60s pay substantially higher premiums than people in their 30s.  Statistically, health care costs increase with age, and it would stand to reason that if people could continue buying their own health insurance past the age of 65, the prices would continue to climb rapidly.

Out of curiosity, I ran quotes for a perfectly healthy non-smoking, 64 year old male living in Pueblo.  The premiums for my hypothetical client ranged from $123/month for a bare-bones, $10,000 deductible policy with 50% coinsurance, all the way up to $1,788/month for a very comprehensive, 100% coverage HSA plan with a $1,200 deductible.  Most of the popular policies were in the $300 – $500/month range.

I’m not able to run quotes for an 80 year old, but obviously the premiums would be significantly higher for an 80 year old than for a 64 year old, if such policies existed.  Even if Mr. Abbate has chosen to have the very best Medigap and Medicare D coverage he can get, my guess is that his combined monthly premiums for his health insurance is a fraction of what it would cost if he were buying all of his health insurance from private carriers.  I wonder if he would still be saying “If I can’t afford health care, that’s my problem…” if his only option were to purchase his own policy at 80 years of age?

Individual health insurance is a great option for people who are healthy, and especially those who are relatively young.  For people who are self-employed, it’s a good alternative to higher-priced group of one policies, and it gives people the flexibility to pursue entrepreneurship without being tied to employer-sponsored health insurance.  But the price increases with age, and many early retirees find it a challenge to pay for health insurance during the years before they are eligible for Medicare.  My guess is that even if private individual policies could be purchased by people over the age of 65, very few people would take that option, simply because of the price.

We currently have 50 states with 50 different levels of health care regulation.  For people who are ill, some states are much better places to live than others.  State-driven health care reform could theoretically be expected to increase the populations of sick people in states with very patient-friendly laws, thus driving health care costs even higher in those areas.  No state is an island.

Since much of the health care reform debate comes down to money, I think David’s comment that “…the federal government has an easier time running large deficits than the states do.” is the most pertinent point of all.  Basically, the logistics of genuine health care reform could bankrupt many states.  It might run the federal government into a good deal of debt too, but the feds have more avenues for dealing with debt than the states do.

I feel fortunate to live in a state where we have a solid high risk pool (Cover Colorado) and lots of options for policies in both the individual and group market.  But I can’t help but think of people who live in states where there aren’t any health insurance policies available to people who are sick and not covered by an employer’s plan.  Or people who live in states where health insurance is guaranteed issue but not mandatory, and thus extremely expensive.  For them, health care reform on a state level has a long way to go, and might not happen at all.

David’s article was included in last week’s Health Wonk Review, hosted by Brad Wright at Wright On Health.

My guess is that the people who want congress to stop working on health care reform are those who have great health insurance that is largely funded by an employer.  Or they may be very wealthy individuals who have little if any concerns about  paying for unexpected medical bills.

One of the biggest obstacles to public support of health care reform is all the different avenues by which Americans get their health insurance and health care.  People who live in towns with great public clinics that provide services based on a sliding fee scale might not be is such bad shape, even without health insurance.  People who have excellent employer-sponsored health insurance are also doing pretty well in terms of health care.  Even public health insurance varies from one state to another, with some states having much more restrictive limits on who qualifies for programs like Medicaid.  And the simple fact remains that most Americans get their health insurance from their employers, and are thus relatively insulated from the whole process of purchasing health insurance and dealing with problems like pre-existing conditions and medical underwriting.  In addition, rate increases on group plans are partially paid for by employers, which means that the impact of rate hikes in the group market isn’t felt as strongly by individual members as it is in the individual market.

The people who are hurting the most are those who purchase their own health insurance, and people who work for very small businesses that struggle every month to continue to pay the premiums to keep their policies in force.  These people make up a relatively small percentage of the population, and their voices are being drowned out by all the people who don’t have to deal with the issues being addressed by health care reform.

Anthem charges the same premiums regardless of whether a policy is new or has been in force for several years.  A 40 year old, healthy, non-smoking male who purchases a policy this month will be paying the same premiums as a 40 year old healthy non-smoking male who has had an Anthem policy for ten years, assuming they both live in the same zip code and have the same type of policy.  Because of this, it’s relatively easy to compare Anthem’s rates – even after rate increases go into effect – with those of other carriers in Colorado.  The rates being offered to new Anthem clients include the rate increases that went into effect in January.

To get an idea of how Anthem’s prices compare with other carriers, I got quotes for a family of three, living in the Denver metro area, for a high deductible, HSA-qualified policy with 100% coverage after the deductible.  These plans are relatively easy to compare, as they tend to be quite similar from one company to another.  I looked for policies with a $5000 or $6000 family deductible (most companies offer one or the other, but not usually both), or something in the middle of that range if neither exact number was available.

Here’s what I found, from several of the top carriers in the Colorado individual market:

• Cigna = $325 (for a $6000 deductible)
• Anthem Blue Cross = $377 (for a $5000 deductible)
• Humana = $402 (for a $5000 deductible
• Kaiser = $441 (for a $6000 deductible)
• Assurant/Time = $449 (for a $5700 deductible)
• United HealthOne (Golden Rule) = $461 (for a $5800 deductible
• Aetna = $481 (for a $6000 deductible)

Obviously this isn’t comprehensive data.  I only got quotes for one family, using a single zipcode.  Factors like pre-existing conditions, tobacco use, zipcode, and plan design all have an influence on premiums.  But these numbers would seem to indicate that while Anthem’s rate increase may have been large, it seems to be in line with what other carriers are charging in Colorado.  For the little test I conducted, Anthem’s premium was the second-lowest I found, and the only one with a lower premium had an additional thousand dollars in out of pocket exposure.

I’ll be curious to see what the Division of Insurance comes up with when they re-evaluate Anthem’s 2010 rates.  My guess would be that they will approve the rates.  If they don’t, it would stand to reason that they will have to also re-evaluate the most recent rate increases for all of the other carriers in Colorado too.

Wellpoint has been roundly criticized for the proposed rate increases for CA insureds with individual coverage.  The whole situation begs the question: why would they do this if they didn’t have to?  I have to assume that the premiums on their policies will still be in the same ballpark as policies offered by other carriers, even after the rate increases.  Health insurance companies have to compete with each other just as any other private business does.  And for the majority of customers, price is the primary concern.  If a health insurance company sets prices that are dramatically higher than those offered by their competitors, they will quickly find themselves insuring only their current members who are too sick to be accepted by a new carrier, and whose medical expenses are likely outstripping their premiums, even after the rate increases.

In Colorado, we routinely see annual rate increases that vary from 10% to more than 30%.  They’re spread out across all of the major carriers, and over time their prices tend to keep pace with each other.  A company that has a relatively small rate increase one year will likely have a bigger one the next year.  A company with the most competitively priced policy one year is likely to be less competitive the next year.  And people shop around; many of our clients ask us to revisit their policy options every few years.

I will be interested to see more on the Wellpoint story as the rate increases are investigated this spring, but I imagine that it’s not a simple problem or one that has a simple solution.  It’s true that Wellpoint is in business to make money.  But a dramatic, highly publicized rate increase is bad for business, and it’s hard to explain it away as a company simply trying to raise profits.

Jaan’s article was included in the Cavalcade of Risk this week, hosted by David Williams at the Health Business Blog.

The recent debate over the Wellpoint premium increases should be a warning sign that premiums will not be controllable unless we add more healthy people to the insurance pool.  When I read through the President’s proposal, I see lots of things that will be beneficial to the average insured person – especially those of us who buy our own health insurance on the individual market.  No more denials because of pre-existing conditions, no annual or lifetime benefit caps, and plenty of tax subsidies for a lot of families.  But the mandate requiring everyone to carry coverage is still very weak.  I guess it makes sense that it isn’t dramatically changed, given that the President’s proposal is a compromise between the House and Senate bills, but it’s still disappointing.

In the President’s compromise, the annual flat dollar penalty for those who can afford health insurance but choose not to carry it would start at $325 in 2014, and go up to $695 in 2016 (indexed thereafter for inflation).  The alternative penalty (people would be charged whichever amount is higher) is based on an percentage of income, and would start at 1% in 2014 and go up to 2.5% in 2016.  To Obama’s credit, the percentage of income penalty in his proposal is significantly greater than what was proposed in the Senate bill (0.5% in 2014, going up to 2% in 2016).  But I just don’t think this is going to get the job done.

Let’s look at the average American family earning $50,000 a year.  Let’s say they choose not to carry health insurance.  1% of their income would result in a penalty of $500 in 2014.  By 2016, that penalty would equal $1250.  My own family has a “bare bones” health insurance policy that will cost us about $4000 in premiums this year.  We have a high deductible ($5000) HSA qualified plan, and other than some preventive care, all of our expenses go towards our deductible (although we do get some great network-negotiated rates).  It would be tough to find a less expensive policy (in Colorado anyway) without significantly increasing our out of pocket exposure or ending up with lots of holes in our coverage.  So even with a high deductible policy, our premiums are eight times as much as the penalty that would be assessed against the average family for not carrying health insurance, in the first year of the program.

If people know that they won’t be penalized for pre-existing conditions and that health insurance companies will have to accept everyone, a penalty that is just a tiny fraction of the cost of coverage might be the preferred option for a lot of people.  And without a large pool of healthy insureds, I just don’t see a way that premiums won’t increase significantly.  I’m keeping an open mind, but I’m skeptical that we’ll be able to provide all of the proposed consumer benefits with such a lax enforcement of mandatory health insurance.

Last fall, I wrote an article about what happens when health insurance is guaranteed issue but people are not required to maintain coverage.  The large premium increases that Wellpoint is proposing are a good example of what happens when young, healthy people have the option to be uninsured.  The recession has crunched budgets for families all over the country.  For people who are healthy, health insurance might have been one of the first things to go.  People who are sick and currently in need of care will go to much greater lengths to keep their coverage.  And thus begins the vicious cycle.  As more healthy people drop their coverage, there is less money to pay claims for people who are sick.  So premiums increase, leading to more healthy people opting to go uninsured.  The 25% – 39% rate increases happened because healthy people dropped their coverage… but there isn’t yet a guaranteed issue mandate requiring all applicants to be accepted.  Imagine how much worse the rate increase would be if that were the case.

Group health insurance premiums increase every year too, but not as quickly as individual policy premiums.  Group plans are partially (sometimes completely) funded by the employer.  Premiums are automatically deducted from paychecks, and the whole process is somewhat out of the employees’ hands.  There just isn’t as much incentive for a healthy employee on a group plan to go without health insurance as there is for a person who buys her own health insurance.  People who buy their own health insurance must pay the whole bill, every month.   When it’s time for their rate increase, there’s no employer shouldering part of the burden.  The option to continue or drop coverage is there every month when it’s time to pay the premium… and if it comes to a decision between the rent or the health insurance, it’s easy to understand how a healthy person might opt to go uninsured.

Eye-popping premium increases will absolutely become the norm if we end up with a system that requires all health insurance policies to be guaranteed issue, without a strong, enforceable measure requiring everyone to be part of the health insurance pool.

The poll found that although people were generally concerned about people who are uninsured, there was little consensus in terms of approval for the health care reforms that congress has worked on over the last year, and people – especially those with high incomes – were worried that health care reform would make their own situation worse.

The fact that 75% of people with health insurance are happy with their current coverage gives a clue as to why there has been so much protest surrounding the reform debate.  When people are happy with their health insurance and hearing a lot of noise from lawmakers about reforms, it’s natural for them to be concerned that their own coverage is going to change.  I think that if people were generally unsatisfied with their current health insurance, the reform process would have been less bumpy.

Nearly 60% of American get their health insurance from an employer.    This accounts for a large portion of the American people, and they are somewhat insulated from the rapidly rising cost of health care and health insurance.  In addition, they generally don’t have to deal with issues surrounding pre-existing conditions.  Employer-sponsored health insurance has large premium increases just like individual policies do, but employers typically shoulder a chunk of the increase, softening the impact on employees.  However, the percentage of people who are covered by employer-sponsored health insurance has steadily declined over the last decade, and more people than ever are having to fend for themselves when it comes to getting coverage.  Perhaps this explains the general sympathy towards those who are uninsured.

The big problem – as usual – comes down to money.  People want to keep their current health insurance and also extend coverage to those who are uninsured, but would prefer to do it without paying additional taxes or health insurance premiums.  Something’s gotta give.  We’ll have to wait and see what congress comes up with next week during their summit with the president, but there’s no way they’re going to make something out of nothing.  In order to provide health insurance for everyone, we’ll either have to give up some freedoms (in the form of a mandate requiring everyone to carry coverage) or pay a little extra in taxes or premiums.

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When we consider mandates, the result is generally higher premiums for everyone, and a greater benefit for the collective population – but not necessarily for each member of the population.  In states where health insurance is guaranteed issue, there is absolutely a benefit for people with pre-existing conditions, but there is also a tremendous cost in terms of higher premiums for everyone in the state.

In Colorado, lawmakers tried to pass a bill this month that would have halted new mandates for a year, but it died in committee last week.  This was followed closely by the passage of a bill introduced by Diane Primavera that will make medically necessary oral chemotherapy a covered expense on health insurance policies.  Primavera had introduced a similar bill in last year’s legislative session, but it didn’t pass.  This year’s version is likely a less costly mandate, since it includes the stipulation that the oral chemotherapy must be medically necessary in order to be covered.  The focus of this year’s mandate was on saving lives, whereas last year’s bill was intended to expand treatment options and make life a little easier for cancer patients.

As soon as the Colorado legislative session got underway last month, there were several bills introduced that focused on health insurance.  It’s easy to see injustices in the health care delivery system, and it’s natural to want to remedy them.  When we see a person suffering from ill health and also struggling to pay medical bills, it’s easy to understand how lawmakers want to mandate more comprehensive health insurance coverage for everyone – nobody should be bankrupted by medical bills or have to choose between getting treatment or having a place to live.

But the cold reality of money is hard to ignore.  The fact remains that every time we mandate additional benefits for health insurance coverage, we drive premiums up for the whole population.  And that invariably results in some people – who may have been right on the brink of being able to afford coverage in the first place – opting to go uninsured.  Which perpetuates the cycle of increasing costs for everyone in order to cover provider losses incurred in our overflowing emergency rooms.

But what if we tried to find a middle ground between those who would like to see every health condition fully covered by health insurance and those who can only afford basic premiums (and thus basic benefits)?  Maybe we could implement a system whereby all policies had to have a deductible of at least a certain amount – a minimum out of pocket.  We could eliminate policies with very low deductible and copays, but do so gradually, with annual deductible increases.  As out of pocket expenses increased, premiums would decrease.  Of course one of the problems with high deductible, low premium policies is that people often don’t have money saved to cover out of pocket expenses when they have a claim.  I can see a few ways around this.  One, we could allow anyone – regardless of what type of health insurance they have – to open a tax advantaged health savings account (HSA).  The money deposited into the account would be tax deductible, and would be available when medical expenses arose.  A second option would be to create “forced” savings accounts and payroll deduct a small amount of money – sort of the way we do now with things like social security and Medicare taxes.  This money would be held in an account in the employee’s name, and would be available if needed for medical expenses.  If it were not needed, it would belong to the employee upon retirement.  To be fair, these accounts should be tax deductible too, and could be waived if an employee showed proof of having their own HSA.  A third option would be a low-interest loan available from the government to help people pay their deductible.

I’d like to see a compromise between people who have health insurance that covers everything with very low out-of-pocket exposure, and those who have minimal coverage and huge financial exposure in the event of a serious illness.  Most of the very high end policies are group coverage, and are usually funded in large part by employers, which means that a lot of people truly have no idea how expensive their health insurance is.  And a mandate that increases coverage and cost is likely to be felt more by the employer than by the employee.  But it will be felt especially hard by people who pay for their own health insurance, with no help from an employer.

We cannot continue to just tack on more mandates that increase health insurance benefits without addressing the inevitable premium increases that will follow.  We absolutely need to address the problem of people facing staggering bills when a medical condition is not covered at all by their health insurance, but if we continue to add mandates without looking for ways to bring down costs, we’re only going to push more people into being uninsured.