On Health Care, a Warning from the States

Big talk of reform dried up in the legislatures

The news from the states about reforming health care is less than promising. You might even call it grim, foreshadowing what awaits any candidate—for Congress, the statehouse, the governor’s office, or the presidency—who is serious about changing the system: it’s going to be tough, a point some of the media have begun to make.

For starters, efforts to achieve universal coverage are turning into options to buy bare-bones insurance policies. During the primary campaign, there was tons of talk about achieving universal coverage but precious little about what is actually meant by “coverage.” The Palm Beach Post and The New York Times have now given us a clue. Florida legislators in the session just ended decided to allow insurers to sell policies that will cost no more than $150 a month and offer very limited benefits, which both advocates and insurance experts say are unlikely to cut the number of uninsured in the state, that now includes nearly one quarter of Floridians. The policies will cover annual check-ups, mammograms, and prostate screening, but if screening reveals cancer, good luck—treatment and hospital stays may not be covered. Insurers could offer such coverage, but may limit the number of days for a hospital stay or cap the amount it will reimburse. Either way, the people who need these policies would get screwed.

So the prognosis isn’t great that people will flock to buy these slimmed-down policies, even though Governor Charlie Crist has said that if even one person buys a policy, the law “would be a success.” Go figure.

Meanwhile, the Commonwealth Fund, a philanthropic organization based in New York City, just released a study showing that last year there were 25 million underinsured adults in America, 60 percent more than in 2003. The Fund identified people as underinsured if they spent 10 percent or more of their income on out-of-pocket medical expenses, or if they had deductibles equaling 5 percent or more of their income. One reason for the sharp increase, says the report, are policies that limit benefits such as the amount reimbursed for care or the number of doctor visits allowed. As a result, according to the Fund, the underinsured often go without needed care.

Still, other states are eyeing the same “solution” that Florida has landed on. The Denver Business Journal reports how high hopes were dashed when Colorado state lawmakers balked at the cost of some of the proposals put forth by the state’s Blue Ribbon Commission for Health Care Reform, including subsidies for low-income workers to buy commercial insurance policies. Such a strategy is a more politically palatable approach than creating a social insurance program funded through the tax system which would cover everyone, but it still crashed after Governor Bill Ritter said he doubted that Coloradans were ready for such a sweeping, costly health-care reform program. So what did the legislative sausage-grinder produce? Besides expanding eligibility for the State Children’s Health Insurance Program (SCHIP)—a positive step—it cranked out a series of safe, low-cost strategies, including laws to encourage the development of bare-bones policies and the creation of an apples-to apples comparison shopping guide to help people find the policies with the barest of bones.

In Kansas, the failure of health reform signals other difficulties. Kansas Public Radio health reporter Bryan Thompson aired a fine piece that explained why reform flopped this year despite proposals from its own version of a blue-ribbon commission and what appeared to be strong support from legislators. The Kansas Health Policy Authority, a government agency that coordinates the state’s health agenda, had proposed a twenty-one-point plan for reform, including the modest and acceptable premium subsidy program that would help people buy private insurance. But, as in Colorado, that didn’t pass either. Thompson pointed out that only nine of the Authority’s ideas were adopted, and of the nine, only one was funded—a $550,000 program to promote exercise and better nutrition in schools.

What went wrong is a cautionary tale for other reform-minded pols: legislative support collapsed. In an interview with Thompson, Authority executive director Marcia Nielsen noted that “legislators have no problem turning around and voting against a bill they had supported one short year ago.” Opposition mounted to everyone’s favorite funding source—higher tobacco taxes—which ultimately failed to pass. And then there were second thoughts about what “reform” should be. Dr. Robert St. Peter, who heads the nonprofit Kansas Health Institute, said that the discussion needs to move beyond insurance, access, and the cost of care to focus on what produces health efficiently; in other words, programs that get more bang for the buck.

That’s all well and good, but Thompson’s piece showed that lawmakers failed to fund several initiatives that would have done just that, such as dental care and smoking-cessation treatments for pregnant women on Medicaid, and more cancer screening. The legislature did find $2.5 million to help the state’s struggling safety-net clinics keep up with a growing demand for their services. It’s worth noting that it got some of that money by taking it from those cancer-screening programs that were slated for expansion.

Peter, meet Paul. And welcome to health reform in 2009.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.