I like the compromise that the revised bill would create.  It will definitely expand access to maternity care for women in Colorado.  Right now, there are three health insurance companies here that offer maternity care:  Assurant, United HealthOne, and Rocky Mountain Health Plans.  The RMHP maternity option is very expensive.  The United HealthOne option isn’t terribly pricey, but the benefits are low for the first couple years after the policy goes into effect.  The Assurant policy is the most popular among our clients, but it requires that the client meet a separate maternity deductible before benefits begin.

For a woman in Colorado who does not have an option for group health insurance and is contemplating pregnancy, the choice is either to opt for paying for the pregnancy out of pocket (complications are covered on all policies), or to switch to one of those three health insurance companies that offers maternity benefits.  Most of the big-name health insurance companies – Anthem Blue Cross Blue Shield, Aetna, Cigna, Humana, Kaiser, etc. – wouldn’t be an option for her at all if she wants to have maternity benefits.  Right now, if a woman has her heart set on using a particular health insurance company and also on having maternity coverage, she’s likely going to have to pick one or the other.  If HB 1021 requires each insurance company to offer at least one policy with maternity benefits, the number of options available to women seeking maternity coverage would increase dramatically.  I have to assume that the increased competition would help to lower costs for this coverage.  It also  makes sense that if women had more options for coverage, more women would likely elect to add maternity to their policies, thus increasing the pool of insureds with maternity coverage, further driving down costs.

It would be nice to see more options available for our clients who are looking for maternity coverage.  My preference would be if clients could select their health insurance policy based on all of the other features of the plan, and then add maternity benefits after they had settled on a policy, rather than choosing a policy by default simply because it is one of a very few options that offer maternity benefits.

All three of these changes sound good at first glance, but the first two are not as cut and dried as they sound.  Ending gender-based pricing in the individual market would likely result in lower premiums for women, but higher premiums for men.  In Colorado, men are more likely than women to be uninsured, and raising their prices would almost certainly mean that more of them would drop their coverage.

Adding reproductive services also sounds like a good idea, but it depends on how much it would increase premiums, as many people already struggle to afford their health insurance.  For people like me, who choose to have homebirths with midwives, would we be paying for maternity coverage and still paying out of pocket for our midwives?  Would people who choose to adopt or not have children be forced to pay for maternity coverage?  Would people who would rather have a high-deductible, HSA qualified policy still have to pay for maternity coverage?  There are a lot of questions around this topic, and I still haven’t seen any solid data indicating how much health insurance premiums would increase if reproductive services were included on all policies.  Group policies in Colorado are required to cover maternity care, and the premiums are far higher than individual policy prices.  But group policies are also guaranteed issue, and it’s hard to tell how much of the premium difference has to do with underwriting and how much has to do with things like maternity care being covered on group plans and not on individual policies.  Currently there are only a handful of individual carriers in Colorado that offer maternity coverage (Rocky Mountain Health Plans, Assurant, and United Health One), and with all of these carriers, the addition of maternity coverage makes the policy significantly more expensive.  Obviously the premium difference wouldn’t be as dramatic if the coverage price were spread across the whole population via a mandate, but I am concerned that it might not be a small rate increase.

The bill that would require standardized EOBs does have my support, as does any legislation that would make health insurance benefits and claims information easier to understand and compare.  Anything that can reduce the amount of time that medical offices and consumers spend trying to figure out benefits and claim information will ultimately make our health care system more transparent and efficient.

If you have an opinion one way or another on these or any of the other bills that were introduced this week, now is the time to contact your representative.

When our son was born, we opted for a homebirth with two registered midwives.  We had to pay for their services ourselves, since we have an individual health insurance policy that doesn’t cover maternity (none of the individual carriers in Colorado that offer maternity coverage will pay for a homebirth – this is also the case with most group plans that cover maternity).  We received fantastic prenatal care throughout my pregnancy and delivery, and the $3000 that we paid was well worth it.  And since we don’t pay for maternity care on our health insurance policy, it made sense that we would pay for our midwives’ services ourselves.  If complications had arisen, our health insurance policy would have kicked in, as all policies in Colorado – individual and group – cover complications of pregnancy.

New mothers and infants account for nearly a quarter of all patients discharged from hospitals, c-sections are the most commonly performed surgical procedure in the US, and maternity and newborn care amount to more hospital charges than any other type of care.  If health care reform ends up mandating that maternity care be included on all individual health insurance policies, there is no doubt that it will lead to increased premiums.

If we decide to have another child, we will most definitely opt for another midwife-attended homebirth.  We would expect to have to pay for it ourselves, but I would be extremely frustrated if we were also having to pay for maternity care on our individual health insurance policy at the same time.  I hope that if maternity care becomes a requirement on individual health insurance policies, it will cover both OBs and midwives, wherever a woman chooses to give birth (hospital, birth center, or home).

Amy Romano has written an outstanding article comparing modern American maternity care with SUVs.  Since maternity care takes up such a huge portion of our health care budget, this article is a worthwhile read for anyone concerned about the spiraling cost of health care.  Hopefully the points that Amy makes will be taken into consideration when lawmakers decide what services should be covered by all health insurance policies.

I found Amy’s article in Grand Rounds, very creatively hosted at Florence dot com.

One of the major aspects of health care reform that has gained a lot of traction this year involves doing away with medical underwriting on individual health insurance policies, and would require health insurance carriers to accept all applicants, regardless of health history.  Obesity is considered a pre-existing condition by all of the individual health insurance carriers in Colorado.  Obviously applying these standards to a healthy, breastfeeding baby is ill advised, but I believe it makes sense for adults.

The guidelines are currently pretty lenient when it comes to weight.  Most carriers start to increase the premiums on their policies if an applicant has a BMI of around 30 – which is the cutoff for obesity, according to the CDC.  Being overweight, but not obese (BMI of 25 to 29.9) doesn’t result in a rate increase at all with many carriers.  So a 5′5″ female can weigh up to 180 pounds and still qualify for a standard rate with many of the individual health insurance carriers in Colorado, assuming she is a non-smoker and doesn’t have any other pre-existing conditions.

I’m curious to see what happens to underwriting regarding obesity and tobacco use as health care reform moves forward.  Both of these factors are known to increase health care costs.  They’re also factors that each person can control – not saying that it’s easy, but it can be done.  I can see the benefit to making sure that everyone gets accepted for health insurance, regardless of weight, as it’s counterproductive for society as a whole to have people who are uninsured.  But I believe that it makes sense for obese applicants, and tobacco users, to pay more for their health insurance in order to offset the higher claims they are statistically likely to have.

I’m curious to hear what our readers think about this topic.  Should obese applicants pay more for their health insurance than normal weight applicants?  What about smokers?  Does this amount to something akin to a regressive tax, since lower income people are more likely to be overweight, and also more likely to be smokers?  Should income then be taken into consideration when setting health insurance premiums?

I don’t know what to say that Gawande hasn’t already said.  I think that the article should be required reading for everyone in the health care industry.  Doctors, nurses, hospital administrators, health insurance executives, pharmaceutical company employees, and health insurance agents – we all need to read this article.  And really think about it.  There’s a quote in the article from a doctor who says “we took a wrong turn when doctors stopped being doctors and became businessmen.“  I would take that a step further and apply it to the entire health care industry.  We are not in a luxury products industry, or one than can be funded with discretionary income.  We all need to take a long hard look at our motivations and what we consider to be our primary responsibilities.  Anyone who puts making money at the top of the list might be better served in a different profession.  Obviously, making money will be somewhere on the list – we all need an income.  But the health care industry isn’t a place where money should be the driving factor.

I was pleased to see that Grand Junction, Colorado was mentioned in the article as an example of a city where health care costs have been reigned in by cooperation between physicians and encouragement from the main health insurance company in town (the article doesn’t name names, but my guess is that the HMO in question is Rocky Mountain HMO, which is based in Grand Junction).  Hopefully Gawande’s article in the New Yorker will encourage other cities to emulate the model that Grand Junction has created on Colorado’s western slope.

The point is, there really is no one-size-fits-all when it comes to health insurance.  In terms of health care reform, unless someone just starts handing out free health care (without tax increases or premiums…), it will be tough to get people to agree on a single plan, or even a handful of coverage options.

Each state has its own regulations in terms of what all policies in that state have to cover.  The rules are different for group and individual health insurance.  In Colorado, for example, all policies have to cover well-child care, PSA testing and mammograms (based on age).  All group plans have to cover maternity, but individual plans do not.  There are a handful of individual carriers in Colorado that do offer maternity as an optional benefit (Assurant, United HealthOne, and Rocky Mountain Health Plans) but the majority of individual plans do not.  This is because the state doesn’t require it, and the market won’t support it (the premiums are expensive, and very few people choose to pay the extra premiums for maternity care on individual health insurance policies).

For people who get their health insurance coverage from their employer, there aren’t likely to be a lot of choices in coverage, but the employer is probably subsidizing a good chunk of the premiums, which makes it easier to accept whatever is offered.  For people buying health insurance in the individual market, there are lots of options, but pricing and medical underwriting can often limit the choices.

Bill Kramer has written an article about the issues involved in designing a national benefit plan.  Overall, the process and compromises involved sound a lot like what goes into designing private health insurance policies: a delicate balance between cost and coverage, targeting the widest consumer group possible.  The major advantage that the private health insurance market has in this regard is that it can implement a wide range of options, with policies ranging from bare-bones catastrophic coverage to very comprehensive “gold-plated” coverage.

If health care reform ends up involving a public, national health insurance option, it would be wise for them to offer multiple plan designs in order to give people choices in terms of premiums and coverage.  Otherwise, it’s unlikely to appeal to a large number of people.

I found Bill’s article in the Health Wonk Review, hosted this week at Health Care Policy and Marketplace Review, written by Robert Laszewski.

My concern is that non-profit does not necessarily mean low cost and efficient.  Profit is what is left over after expenses are calculated, and those expenses include everything from CEO salaries to artwork in hospitals.  Another bonus for non-profit health insurance plans – as with any non-profit – is that they can apply to the IRS for income tax exempt status, and many do.  Here in Colorado, Kaiser is tax exempt, and has had to work deals with our insurance commissioner recently to determine how to best utilize the $700 million that they had in reserves.

As a test, I got quotes for myself for a $5000 deductible HSA qualified plan with 100% coinsurance from six different Colorado health insurance carriers: Aetna, Anthem Blue Cross Blue Shield, Assurant, Humana, Kaiser, and United HealthOne (Golden Rule).  The prices ranged from $78 to $130.  Kaiser was $93, higher than Assurant, Anthem Blue Cross, United, and Humana.  So although Kaiser is a non-profit health care system, in the individual market they are not providing less expensive health insurance than the for-profit health plans in Colorado.

I do agree with the rest of the comment: guaranteed issue individual health insurance will only work if everyone is required to buy into the system, and “Who pays the tab doesn’t change the underlying problem that we have runaway demand for very expensive care supplied by an inefficient system.”  One way or another, a lot of reform is needed.

In Colorado, health insurance carriers are not required to pay for behavior therapy for autism. According to the Autism Society of Colorado, several health insurance carriers (including Cigna, Anthem Blue Cross Blue Shield, Rocky Mountain Health Plans, and United HealthCare) in the state agreed a few years ago to treat autism as a “congenital birth defect” and pay for up to 20 visits of occupational, physical, or speech therapy to treat the condition. But behavioral therapy for autism isn’t something you can do for an hour a week. In order to get results, most children need a lot more than 20 visits. And families are being bankrupted in order to get the best treatment they can find for their children.

There are lots of issues here. Obviously autism needs to be treated, aggressively and early. And families shouldn’t have to choose between a child’s treatment and being able to pay the rent. But anytime we mandate additional coverage on private health insurance policies, we risk driving up the cost of coverage, which means some people who were struggling to pay their premiums will go uninsured. So while a mandate would obviously help families with autistic children, the possibility of higher health insurance premiums is bad news for a lot of other families.

Conditions like autism are perfect examples of why a little government involvement in our health care system would not be a bad thing. The Autism Society of America pegs the cost of caring for an autistic child at $3.5 million to $5 million. And with 1 in 150 American children somewhere on the autism spectrum, that adds up to a whole lot of money. In order for private health insurance carriers to pick up the tab for the medical treatments for autism, they would have to generate additional revenue. And that tends to come in the form of rate increases for everyone. But what if the government were to get involved? What if the government stepped in with a program like Medicare for autism?  Eight years ago, my father was diagnosed with kidney failure, brought on by an obscure auto-immune disease. At the time he was covered by a group health insurance policy, which continued his treatment for the first 18 months. After that, he was enrolled in Medicare, even though he was only 55, and Medicare has continued to pay for his care ever since. Medicare covers people with kidney failure, no matter how young they are. And since dialysis is an on-going and costly treatment, the Medicare coverage saves private health insurance companies a huge sum of money. Why not do the same thing with autism? Just like kidney failure, autism requires on-going, expensive treatment. In the case of kidney failure, Medicare negotiates much lower reimbursement rates (compared with billed charges and private health insurance reimbursement amounts) with dialysis centers, hospitals, and nephrologists. I can see the value in a similar program for autism, where any child with autism would be automatically enrolled in a government-sponsored health care plan soon after diagnosis (perhaps just for the autism treatment, with their own private health insurance still in force for non-autism health care). The government could negotiate lower reimbursement rates for therapy, but because all children with autism would be receiving care (rather than just the ones whose families can afford it, as is currently the case), there would be an increased volume for providers, helping to offset the lower per-treatment rate. And the most important part would be that families would be able to get help for their children – early and often – without having to worry about how to pay for it.