As Congress debates health care reform, it is clear that access has emerged as a major issue. And rightly so.  Everyone agrees it is unacceptable that 46 million Americans live day-to-day without health insurance.

The first item on the President’s health reform agenda requires insurance companies “to cover pre-existing conditions” so all Americans regardless of their health status or history can get comprehensive benefits at fair and stable premiums.”

Anthem Blue Cross and Blue Shield agrees that we need to move to a system where all Americans – including those with pre-existing conditions – have access to health insurance. In fact, the health insurance industry announced its support for the elimination of pre-existing conditions as a barrier to eligibility for individual and small group coverage in November of 2008.

But in order for health insurers to offer what is known as “guaranteed access,” Congress must first adopt a comprehensive plan that would require all individuals to keep and maintain health care coverage.  The simple truth is that the health insurance system cannot provide guaranteed coverage for pre-existing conditions unless there is an effective, enforceable individual mandate in place.

Understanding why this would be necessary requires a basic understanding of how insurance markets function.

As readers of the Colorado Health Insurance Insider know, Insurance markets pool risk.  An insurance system will only work if the exposures of low risk individuals are pooled together with the exposures of higher risk individuals.  Life insurance, homeowner’s insurance, auto insurance; they all work the same way. If health insurers are required to offer guaranteed access without an effective mandate requiring all Americans to maintain coverage, there would be a clear disincentive for healthy people to secure or maintain coverage.

Why?  Because such a system would allow people to sign up for health insurance only when they get sick or need care.  This would be the same as allowing people to obtain auto insurance after they have had an accident or secure homeowner’s insurance after their house has burned down. Health insurance premiums would skyrocket for those who keep their coverage leading to a widespread cancellation of policies, ironically, leading to higher levels of uninsured individuals.

Obviously, this won’t work.  It’s not sustainable. Guaranteed issue will require some form of enforceable mandate.

While there has been a great deal of discussion - and a growing acceptance - that full guaranteed issue in the individual market cannot be enacted without an effective individual mandate, there has been little discussion on the details of how an individual mandate would be structured and enforced.

As we see it, an effective individual mandate must have three essential components:

(1) subsidies to ensure coverage is attainable for everyone,

(2) checkpoints to verify that every individual has coverage, and

(3) a penalty for noncompliance.

Given the fact that 82% of the uninsured are in families with a family income below 300% of the Federal Poverty Level, government subsidies will be needed to help lower-income Americans maintain their coverage.

Checkpoints would have to be established to make sure all individuals are carrying coverage on a continuous basis.  To ensure there are no “free riders,” the checkpoints would have to be structured in a way that is designed to capture 100% of the population that is eligible for “guaranteed issue.”  The tax filing process could be one checkpoint, but others must also be employed such as renewal of a driver’s license, school enrollment or applying for a federally-backed student loan or mortgage.

A new federal health insurance database (or databases at the state level) would need to be established that has the capability to confirm the coverage of every person eligible for “guaranteed issue” coverage.

And lastly, there must be a significant penalty for noncompliance.  The penalty must be greater than the cost of coverage and applied for each month where coverage lapsed.

Anthem and other private insurance companies are committed to working with government leaders and stakeholders to improve America’s health care system.  As this process begins in earnest, it is important to make sure that the efforts to reform are more than just well intended; they need to be effective.  We want to make sure that all Americans have health security and access to quality affordable health care.  We must make sure that the reform measures do not lead to unintended consequences.

Maintaining a balanced individual market in a “guaranteed issue” environment is especially challenging.  Guaranteed issue must be paired with a well-structured, effective individual mandate and sufficient government subsidies to assure that premiums remain affordable.

To take action, please visit: www.healthactionnetwork.com

John Martie, President

Anthem Blue Cross and Blue Shield in Colorado

Individuals who are chronically ill already have to deal with many challenges in their lives. Chronic illnesses include Alzheimer’s disease, diabetes, multiple sclerosis, asthma, arthritis, and chronic obstructive pulmonary disease (COPD). A new study conducted by the Commonwealth Fund in eight industrialized nations has found that chronically ill patients have a relatively greater struggle in the United States. About 138 million people in the United States have chronic conditions. 23% of Medicare recipients suffer from five or more chronic illnesses and result in over half of total Medicare expenditures.

Americans pay more for health care than individuals in other countries. Often, that health care is poorly coordinated, driving up costs for both insured and uninsured patients. In the drive to increase revenues, patient care often suffers. The Americans in the study were most likely to report errors in prescriptions and diagnostic tests, which could lead to serious negative outcomes for patients. In many cases chronically ill patients can’t even get insured at all, because insurance companies can choose not to cover individuals with preexisting conditions. Uninsured patients fare even worse in the United States.

Over half of all Americans have gone without needed health care (such as doctor visits, medications, and other treatments) due to cost. In most cases, it’s preventative care that suffers. That neglect leads to far higher costs for patients and society in the long run. In light of this study, many are calling for health care reform in the United States.

I am paying COBRA, health and dental at $640. per month.
I am a nurse, recently diagnosed with cystic fibrosis (CF) at age 50, this year.
Cobra is 18 months with 11 month extension. I was informed I have to exhaust COBRA timeline before being eligible for Cover Colorado, the High Risk Pool.
CF is a respiratory illness that uses the same meds as any other respiratory disease. Nat’l Jewish sees patients a minimum of 4x per year, more if other symptoms occur as in diabetes.
Asthma patients use nebulizers just as CF pt’s do.
Tobramycin for pseudomonas is inhaled for CF pt, It’s an available medication. Therefore, if you have a non CF patient that has pseudomonas in their lungs, the treatment is the same. I don’t understand why CF has to be in the high risk pool. All other symptoms related would need to be treated at any other hospital. Additionally, CoverColorado is still more expensive for women/non smokers at age 50 than it is for men. We still make less in the workforce and have to pay more for health insurance. after age 50, women are nonchild bearing. So, why is there unequal costs. Also, CF at age 50 is definitely a shorter life span and I would probably need health insurance as long as 5-8 years. I’m paying for COBRA mostly because I need health insurance to “qualify” for future policies and exclusion waiting periods and in case I need it for non CF injuries/illness. I get my medications via the VA at no cost. Currently, I use Denver Health pharmacy or VA which lowers my out of pocket expenses. I think my insurance costs should be lower because of VA benefits. Would someone please address these concerns. Thank you so much. J.A., RN

• The opinions expressed in the “Open Mic” category do not reflect those of Insurance Shoppers, Inc. or the Colorado Health Insurance Insider. If you have an “open mic” topic you would like to submit, please visit our “Be A Guest Blogger” page, or contact us with your submission.

The opinions expressed in the “Open Mic” category do not reflect those of Insurance Shoppers, Inc. or the Colorado Health Insurance Insider. If you have an “open mic” topic you would like to submit, use the “contact us” tab at the top of the page to email your letter to me.

Without further ado, here is our first open mic submission…

The End of Healthcare As We Know It: An Open Letter
by
Tim McGettigan

Dear Anthem Complaints Department:
On August 17, 2007, I was admitted to St. Mary-Corwin Medical Center in Pueblo, CO. for an outpatient MRI. Last week, I received a bill including not one, but two co-payments for the MRI. After looking into the matter, I discovered that my insurance company, Anthem Blue Cross-Blue Shield, is demanding two separate co-payments for this particular treatment because, Anthem claims, the MRI included two distinct procedures.
Frankly, I find this puzzling. Anthem’s request for two co-payments appears to be nothing more than a transparent attempt to squeeze additional sums of money from customers who are already paying way too much for medical insurance. From my perspective, on August 17, 2007, I was admitted to the St. Mary-Corwin Medical Center once (and only once!) for one (and only one!) MRI. Thus, I believe that I should be responsible for one (and only one!) co-payment. However, as anyone who has ever tried to communicate with an enormous, faceless medical insurance bureaucracy has learned, the thoughts and interests of individual patients are of little concern. What matters is money: the bottom line. And Anthem’s new “a la carte” co-pay policy ( i.e., without prior notification, Anthem can be charge its patients more than one co-payment for any particular hospital admission or procedure) is nothing more than a devilishly clever way to fatten Anthem’s bottom line.
Just imagine, if you will, the can of worms that Anthem’s new “a la carte” co-pay policy opens. When medical insurance companies claim the right to demand two co-payments for one MRI, then what’s to stop them from requiring multiple co-payments for every other procedure that takes place in a medical office? So, what’s next? Separate co-payments for blood pressure tests, ear exams, knee reflexes? The sky’s the limit!
Eureka! Insurance companies have struck gold…again!
Of course, the only downside to this lucrative new policy is the fact that the few remaining Americans who can still afford health insurance will no longer be able to use it. What middle class American will be able to risk seeing a doctor when their insurance company is at liberty to charge multiple co-payments on a whim. I can see it all now: In the not too distant future, Doctors will say to their patients, “Stick out your tongue and say, Aaaahh!” and patients will be forced to respond, “Geez, Doc, I wish I could, but I just can’t afford another co-payment.”
Oh, the humanity!
In conclusion, I humbly call upon the powers that be at Anthem Blue Cross-Blue Shield to rescind their “ala carte” co-pay policy. I hate to cut into Anthem’s expanding profit margins, but, at the rate we’re going, pretty soon not even Donald Trump will be able to afford an office visit.
Please do what you can to rectify this sorry state of affairs.

Sincerely,
Timothy McGettigan
Tim McGettigan, PhD, is a Professor of Sociology at CSU-Pueblo