Reality Check for the White House

Axelrod’s e-mail raises more questions

Last Thursday, in an attempt to counter the health reform misinformation being propagated by President Obama’s ideological opponents, presidential adviser David Axelrod sent a “Dear Friend” e-mail to scads of people, informing them about eight ways reform provides security to people with and without health coverage; eight common myths about reform; and eight reasons we need health reform now. After receiving the Axelrod letter, someone told me it was “something that made sense about the health care reform discussion.” But another person, whose specialty is health care communications, offered a different take. The e-mail is puzzling, he told me. Some of it doesn’t make sense. So I decided to give it a careful read.

Eight ways reform provides security and stability. These are the same consumer protections the president announced earlier. They include ending discrimination for preexisting health conditions; ending gender discrimination; ensuring carriers don’t drop coverage for the seriously ill; and guaranteeing insurance renewal. As we noted last week, these protections are important—but there’s much more to the story than the White House told. Axelrod’s e-mail didn’t discuss the loopholes in some of these protections—loopholes the public should know about, lest they be surprised when their coverage isn’t what they expected.

Take the one about requiring insurers to cover everybody, no matter how sick they are. But will insurers still be allowed to charge older people more money? That’s the case in Massachusetts, where older people are having a hard time affording coverage. As Maine’s superintendent of insurance, Mila Kofman, told Campaign Desk, “As long as they can rate people up for age, that’s a proxy for health rating.” So what will really change for the carriers?

Or consider another protection—barring insurers from dropping coverage for seriously ill people. Federal law already prevents this, but companies have found a way around it by closing off so-called “blocks of business” which include a lot of sick, expensive policyholders. Insurers direct new, healthy policyholders to other coverage, and leave the sick people behind in what’s called a “death spiral.” Eventually these people will drop their coverage because it becomes unaffordable—which is exactly what companies want them to do. So the presidential promise of protection is meaningless unless companies are also prohibited from engaging in these practices. The White House hasn’t said where it stands on that one.

The president has said that insurance companies must guarantee to renew all policies—but, again, federal law already says all health insurance is guaranteed renewable. The crucial question here is whether companies will be allowed to rescind policies for fraud and misrepresentation, using tactics that hurt consumers—like paying bonuses to company employees if they find any shred of evidence that the policyholder forgot about some long-ago minor illness and “lied” on the application. If insurers insist on such a provision, who will the White House side with?

Eight common myths about health insurance reform. Here’s where Axelrod’s e-mail really got confusing. It was hard to tell whether the myth was the solution or the solution the myth. “Reform will stop ‘rationing’ not increase it,” the e-mail says. That seems like the solution to the “common myth” that a government takeover will lead to rationing. Reform, Axelrod explains, will forbid many forms of rationing now used by insurance companies.

That may happen, or it may not, depending on how forceful the White House will be when push comes to shove in the back rooms of Congress. But there’s a good chance people who don’t qualify for subsidies or can’t afford mandated insurance even with those subsidies will still find that care is rationed, because they have no money to pay for it. No longer is anyone talking about a truly universal health care system that would guarantee care for everyone. The current bills envision that some people will always be excluded. Congress is still trying to decide which ones.

Some explanations in the myth section skip over some important caveats. “We can’t afford reform” is one of the myths. The White House amplifies the point by saying “it’s a myth that reform will bust the budget.” The e-mail lists various ways the president has proposed to contain health care costs. There’s cutting waste, fraud, and abuse (everyone’s for that); reducing overpayments to insurers selling Medicare Advantage plans (highly controversial); coordinating care and streamlining paper work (no doubt a good thing, but not much savings there). Bottom line: Real cost containment—measures like global budgets and spending caps that would actually slow down medical costs and make premiums more affordable—isn’t part of the deal this year. The White House isn’t prescribing stronger medicine because it knows the special interests won’t swallow it.

Eight reasons we need health insurance reform now. Some of Axelrod’s reasons for acting now have been said many times before, both during and after the presidential campaign—for instance, the number of people losing job-based insurance coverage is increasing and sick people can’t buy policies in the individual market. One reason for acting now, dubbed “Hard Times in the Heartland,” mentions that folks in rural areas have a tough time finding primary care doctors. That argument is not persuasive to some of us in New York City, where people with good insurance cannot get appointments with primary care docs because there aren’t many. High-priced specialists who tend to fuel medical inflation rule the roost here. It might have been more persuasive if the White House had acknowledged that people everywhere are having trouble finding primary care doctors.

Another reason for acting is that “The Tragedies are Personal.” Well, yes, most tragedies are. The e-mail says that half of all personal bankruptcies are due to medical expenses. That probably will not change, because the “affordable” policies many people will be able to buy will be the bare bones variety that will be insufficient when serious illness hits. The personal tragedy section also says that “the typical elderly couple may have to save nearly $300,000 to pay for health costs not covered by Medicare alone.” All the more reason for seniors to be scared of reform efforts, and of losing what Medicare benefits they have. Was that what the White House intended to convey?

The next time Axelrod sends a “Dear Friends” e-mail, we suggest he find some writers who can make things clearer. But first the White House must be clear on what it wants out of health reform, and offer the electorate some substance, some clarity, and some direction. Without all that, the public is just going to stay misinformed.

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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.