The second advantage to the system of having the patient pay up front and then get reimbursed is that people by nature will think twice about going to the doctor if they know that they have to pay for the visit themselves – even if they know that most of the money will be reimbursed.  It’s sort of an instant-gratification-in-reverse idea, and helps to reduce over-utilization of health care.

For me, the most interesting part of the article had to do with the fact that the office visit in question was priced at $33.80.  Apparently, that was the entire cost of the visit, 70% of which would later be reimbursed by health insurance.  When was the last time you saw a total office visit charge that was less than $35?  My family has an HSA-qualified policy, so we pay for our own medical expenses until if and when we meet our deductible.  With Jay’s knee surgeries over the last couple years, we’ve had lots of office visits, both with the surgeons for consultations and follow ups, and also with the physical therapists.  The billed amounts have ranged from $63 to $150 per visit, with most of the visits in the $110 range.  Our health insurance policy pays for our son’s well child visits (all policies in Colorado have to cover well child visits before the deductible), but I’ve never seen an office visit charge of less than $100 on the EOBs we get after his check ups.

The cost of an office visit in France is significantly less than it would be here.  Figuring out why, and implementing some of the same strategies here, ought to be part of our health care reform efforts.  All of the effort we’re putting into health care reform seems a bit silly if we continue to pay two or three times as much for basic services as people in other developed countries.

I found Jason’s article in the Cavalcade of Risk, which he hosted this week at The Healthcare Economist.

Mr. Halvorson pointed out that while many developed countries have some form of private health insurance, they also have medical fee schedules that are set by the government and are far lower than average costs for the same procedures in the US.  When average fees for various medical procedures in several countries are shown on graphs, the US bar looks like a giraffe standing in a herd of gazelles.

But Halvorson acknowledged that while fees in other countries are even lower than Medicare reimbursement amounts here in the US, half of hospitals here are losing money, and do so especially when they treat Medicare patients.  So it’s not as simple as just saying that we need to create set fee schedules that are more in line with those of other countries.

In addition, reducing fees would require winning the hearts and minds of an awful lot of doctors.  While it’s true that most doctors make more money than most of the rest of us, it’s human nature to resist a decrease in reimbursement for ones work (especially when they have to contend with soaring malpractice insurance premiums).  The primary care physician shortage is largely blamed on the fact that doctors who specialize can go on to earn far more money than those who choose primary care.  If we significantly reduce fee schedules across the board, will we see a mass migration to private-pay specialties like cosmetic surgery?

Obviously no single health insurance company can set out on its own to reduce reimbursement rates, since the result would likely be that doctors and hospitals would leave that network in favor of other carriers with higher reimbursement rates.  A government-set fee schedule makes sense (and would go a long way towards standardizing our health care costs), but it would likely face tremendous opposition from medical lobbying groups.  No doubt there would be plenty of muttering about how the government is meddling in the affairs of private businesses.  Although there hasn’t been much of a fuss at all about the government meddling in how credit card companies can do business, so I guess it depends on what business is being targeted.

During the interview, Mr. Halvorson noted that countries like Canada, where there is single payer health care, have what he called a “less robust care infrastructure” and he pointed out that as of a few years ago, there were more CT scans in St. Paul than in all of Canada.  He implies that more tests and scans is a good thing, a benefit of our own system. And yet, every performance report I can find places Canada higher than the US in terms of health care outcomes.  Perhaps we could achieve a lower fee schedule – without compromising quality – if we didn’t do so many tests and procedures.

How To Cope With Pain brings us a truly amazing video.  It’s a reminder to be thankful for all that we have, and for the things in life (like this video) that inspire us.  It’s well worth the five minutes it takes to watch it.

Amy Tenderich of Diabetes Mine shares a “would you rather…?” moment from her 9-year old daughter.  It’s a poignant reminder, seen through the eyes of a child, that all of the parts of our lives – even the bad parts – combine to make us who we are.

Kerri Sparling, of Six Until Me, has a very moving story about her pregnancy and how the online diabetes community has helped her along the way.  Kerri has put an immense amount of effort into getting her body ready for a baby, and it’s wonderful to know that things are going well for her and her husband as they expand their family.

The Hippocratic Oaf gives us some glimpses of life as a medical student, detailing interactions with patients and highlighting incidents that remind him to be grateful for his own life and health.

The rest of the articles cover a wide range of subjects, from the perspectives of patients, doctors, nurses, and policy makers.  Read on…

Dr. Val Jones, writing at Get Better Health, has written a very insightful article about how medical malpractice insurance premiums make it nearly impossible for primary care doctors to practice part time.  The premiums aren’t affordable unless the doctor is a specialist, or a full-time PCP.  She points out that our PCP shortage could be remedied by adding more part-time docs.  But in order to do that, malpractice premiums have to become more reasonable.  And in order for that to happen, we need tort reform.  Hopefully the lawmakers are listening.  Maybe if they’re trying to find a PCP in Washington DC they’ll notice the problem Dr. Val describes.

Health Business Blog’s David Williams brings us an interview he did with Dr. Henry Anaya of the VA, a research scientist working with HIV.  Dr. Anaya describes new rules at the VA that require less paperwork in order to give consent for an HIV test, and the benefits of a rapid result HIV test that is done with a swab instead of a needle, with results in 20 minutes.

Dr Rich, writing at The Covert Rationing Blog, gives us a very colorful depiction of the migration of cardiologists to other specialties.  It conjures up images of marauding Huns and defeated Roman Empires.  But in addition to the Western Civilization lesson, it brings up several good points about the territorial nature of specialists, the Medicare reimbursement cuts for certain cardiology procedures, and the options that are available for doctors seeking to replace lost income once the Medicare cuts take effect.

Lauren, from Novel Patient, describes her recent visit to a Sjogren’s specialist.  Instead of getting the answers she was looking for, she is now on a quest for a new diagnosis, as the specialist thinks there is an underlying condition.  While she’s in the midst of such a frustrating situation, Lauren manages to keep a positive outlook.  We wish you well Lauren, and hopefully the visit to Johns Hopkins will provide some answers.

Barb Olson, of Florence Dot Com, writes a very interesting article about a survey of 1000 non-profit hospital board chairs regarding the quality of care that their hospitals delivered.  Only 1% rated the quality of care at their hospitals as worse or much worse than a typical hospital.  But as Nurse Olson points out, it’s typical for people to overestimate their own positive attributes when self-evaluating (the Lake Wobegon Effect).  And in addition, the hospital board chairs generally weren’t well trained on quality measures, so it’s hard to expect them to have a clear understanding of what constitutes quality of care.  Good food for thought for people who are responsible for improving quality of care standards at our nation’s hospitals.

Clinical Cases and Images Blog has an article about a study showing that for married couples, having children has a positive impact on life satisfaction – and that the level of satisfaction increases with the number of children.  I know that our son has added a great deal of happiness to our lives, but I don’t think I’ll test this theory by having a dozen children!

Laika Spoetnik of Laika’s MedLibLog is making it easy for people to combine social networking with an interest in science and medicine.  She’s created Twitter lists pertaining to biomedical journals, medical journals, and scientific journals – making it easy for a person interested in one or all of those subjects to find up-to-the minute articles and commentary.

Dr. Jolie Bookspan, the Fitness Fixer, brings us a detailed post about how to look upward without placing strain on our necks.  I like the part about how our necks are not Pez dispensers – good visual image.  The article is a good reminder that we need to use proper form in all of our daily activities, not just while we’re at the gym.

Nancy Brown, PhD, of Teen Health 411, brings us some insight into what teens want when it comes to their relationships with their parents.  If we think back to our own teen years, I imagine we can all relate.

InsideSurgery has written about Dr. Nidal Hasan, the Fort Hood shooter.  The article delves into the responsibility that doctors have for their patients, and the moral obligation they have to seek help for themselves if they feel that they are being overwhelmed by their responsibilities.  In addition, the article address the fact that physicians who get their training paid for by the military have to expect that during their required years of service to the military, there may be a war, and they may be deployed.  Especially during times of peace, this is food for thought for anyone who would consider having the military pay for their training in return for military service.

Healthline’s Dr. Paul Auerback writes about how physicians who receive training in high-tech environments and then go on to work in settings with less technology often feel uncomfortable about their ability to provide quality care to their patients.  Most teaching hospitals are more technologically advanced then the average small town hospital or clinic where the doctor might end up working, so it might be advisable for the teaching hospitals to incorporate some low-tech training for their students, in order to better prepare them for situations where they might need to improvise in order to help a patient.

InsureBlog’s Hank Stern brings us a very interesting article about a British hospital that will no longer admit expectant mothers with a BMI of more than 34 (210 pounds for a 5′6″ woman).  The hospital’s labor and delivery unit is run by midwives, and not high-tech.  Because they have patients who want to delivery in a low-tech setting (which I can very much understand), they have no plans to make the facility more capable of handling complicated births.  In addition, one has to assume that there would be significant expense involved in making the hospital equipped to handle birth complications.  The ban on very obese mothers (the lower edge of obesity is defined as a BMI of 30) has to do with the higher risk of delivery complications associated with obesity.  I can understand the hospital’s position, but it seems that it would make more sense to go on a case-by-case basis, evaluating the mother’s health during her pregnancy to see if complications arise (for thin mothers, as well as obese ones).  If they do, it makes sense to have them deliver at a hospital that is better equipped to handle complicated deliveries.  It seems that this might serve their purpose better than a blanket ban on all mothers with a BMI over 34.

Dr. Catherine Busch of Child Psych explains the impacts of the mental health parity law that was passed last year.  The law takes effect on January 1, 2010, and will apply to group health insurance policies covering more than 50 employees.  Individual and small group plans are not required to comply with the law, and the law does not require policies – even for large groups – to offer mental health services.  If they do offer mental health services, the benefits have to be equal to the coverage offered for any other medical condition, but we might start to see policies discontinuing their mental health benefits all together under the new law.  Time will tell.

Eve Harris, writing at A Healthy Piece Of My Mind, gives us a clip of comedians Larry David and George Lopez discussing the results of an ancestry DNA test.  It’s lighthearted, but does make one wonder about the accuracy of direct-to-consumer DNA testing that claims to be able to scientifically determine our ancestry.

HealthBlawg’s David Harlow gives us an intro to what he calls Son of HIPAA – the new federal regulations that went into effect in September regarding protected health information and how data breaches are to be handled and reported.  As medical data is increasingly stored and transmitted electronically, these rules are both necessary and cumbersome, depending on your perspective.  David’s article is a good primer for providers and patients alike.

Allergy Notes explains that IL-33 is a newly-discovered marker of severe asthma.  In a study of people with mild, moderate, and severe asthma, along with non-asthmatic control subjects, those with asthma showed higher levels of IL-33 than those without, and the difference was especially pronounced in cases of severe asthma.

Elyse Nielsen, writing at AntiClue, details the information technology component of opening a new hospital.  One of the aspects that stood out for me was that we should work to eliminate multiple systems that serve the same purpose.  IT is the way of the future in medicine, and much has been said about the ability of technologically advanced systems to save health care dollars.  But this will be especially true if we make sure that our IT systems are as efficient as possible, with no redundancy.

Ryan DuBosar, writing at ACP Hospitalist, tells us about the results of a study that indicates that men with sleep apnea who are treated with nasal positive airway pressure (NPAP) improve their golf handicaps compared with control subjects.  Not surprising, since a better night’s sleep is probably linked to improved performance in nearly every activity.  But promises of a better golf game might make people more likely to be compliant with their treatment.

Laurie Edwards, writing at A Chronic Dose, reminds us all that unsolicited advice is rarely appreciated.  The H1N1 vaccine (along with the seasonal flu shot and pretty much any other vaccine you can think of) is a controversial topic, and it gets people fired up.  But each of us need to make our own decisions, for ourselves and our children, regarding whether to get the shot.  Our health care providers can be expected to weigh in with advice – that’s their job.  But no matter how strongly any of us feel one way or another about the vaccine, it’s not right to give unsolicited advice to other people, especially when we know nothing about their medical history.

Dr. Charles, of The Examining Room, has a very thorough article about Desiree Jennings, the Redskins cheerleader who was supposedly stricken with dystonia following a seasonal flu vaccine in August.  I remember seeing the clip on the news of Desiree, but hadn’t followed the story since then.  Dr. Charles’ article uncovers quite a few details that are worth reading.

ACP Internist’s Ryan DuBosar explains how easy it was for him to get the H1N1 vaccine.   He was able to get it at the county clinic without even standing in line – even though his baby’s pediatrician and his family doctor didn’t have the vaccine available at all.  It does seem to be pretty random in terms of where the vaccine is available and to whom.  In our own family, we have childless adults who have been able to walk right into their doctor’s office and get the shot, along with families with small children who were told they had to continue waiting.

Thanks to everyone who submitted articles for this edition of Grand Rounds.  They were a pleasure to read, and we’re honored to be your hosts this week.  Grand Rounds next week will be hosted by How to Cope with Pain.

Flickr Photo Credits:

• Thanksgiving dinner – CarbonNYC
  
• Leaf – ZedZap
  
• Thanksgiving drive – katmere
  
• Tree – OakleyOriginals
  
• Thanksgiving Turkey- xybermatthew

First, we have an overview of the bill.  Then there’s an article devoted to the public option and insurance exchange.  Next, you can read about how the reforms will impact delivery systems.  And to round things out, there’s an article that details the last minute changes to the bill (like the Stupak amendment).  A big thanks to Professor Jost for making the reform bill so easy to understand.

Now that we all understand what the House of Representatives has been up to lately, I’d like to highlight a few other posts that I particularly enjoyed this week:

Dr. Glenn Laffel, writing at EHR Bloggers, has a very insightful article about how the public option “compromise” that would allow states to opt out is likely to only muddy the waters and create a fragmented “public option” available to people depending on where they live.

Dr. Roy Poses shares a fascinating account of alleged transplant fraud involving liver transplants, Japanese organized crime bosses, and the UCLA medical center.  Transplant lists are the norm for people awaiting new organs in the US, but apparently – for a price – one can jump to the front of the line.  Well worth reading.

Dr. Brad Flansbaum, writing at the Hospitalist Leader, gives us a gem of an article about how health care reform is portrayed in the media, what people – including lawmakers – really understand about the various reform proposals, and the impact of buzz words on popular perception.  I particularly liked his take on comparative effectiveness research, which some have said would put a “government bureaucrat between you and your doctor.”  Dr. Flansbaum’s response is that the “government bureaucrat” is “likely a health services researcher, and someone [he] would look to for guidance even for [his] own family’s health.”

Jaan Sidorov of the Disease Management Care Blog examines a published medical article that reviews the merits of “decrementally cost effective treatments.”  These are treatment options that involve a tradeoff between significant cost savings and a relatively smaller loss of effectiveness.  When it comes to medical treatment, we (especially here in the US) tend to focus on newer and better all the time.  But our medical innovations are often much more expensive than the treatment they are designed to replace.  And sometimes we can have treatment that is nearly as good, for a fraction of the cost.  Jaan says that our failure to bend the cost curve (terminology that Dr. Flansbaum specifically allows to be included in a worthwhile article) means that we’ll need to examine this closely in the not too distant future.

I decided to include two articles from Brad Wright, the voice behind Wright On Health Care.  They were both too good to pass up, and both good enough to land themselves in my editor’s choice section.   First, he gives us a visual breakdown of who the uninsured are, where they live, how healthy they are… demographics in general.  And he comes to the conclusion that the people voicing the strongest opposition to health care reform are part of the same demographic that makes up the largest uninsured sector of the population.  This isn’t a new idea, but the way Brad goes about detailing the evidence is highly compelling.

Brad also brings us his take on the Stupak amendment, which would prohibit health insurance from paying for abortions unless the mother’s life is in danger, or in cases of rape or incest.  He points out that the vast majority of abortions are currently not paid for by health insurance.  I agree with him that this amendment was designed as a wedge to divide people over a hot button issue, rather than as something of substance.

Rounding out the rest of the Health Wonk Review are a variety of good articles organized roughly by topic:

HEALTH INSURANCE:

Anthony Wright gives us an article about the weak employer mandate in the health reform bill, which would only impact large companies, and would only penalize employers by a fraction of the actual cost of providing health insurance if they choose to ignore the mandate.  Anthony points out that throughout the entire health care reform debate, lawmakers have repeatedly said that people can keep their current health insurance if they like it.  More Americans get their health insurance from their employers than any other single source, but that percentage has been declining in recent years as the cost of health insurance continues to climb.  Anthony notes that if employers keep discontinuing health insurance benefits, people might not actually have a choice of keeping their current plan, regardless of whether they like it or not.

Health Access Blog’s Beth Capell brings us a sobering discussion about the ramifications of being an uninsured child.  While it’s relatively rare for a child to die, Beth looked at a study that found that half of the children who died following a hospitalization between 1988 and 2005 were uninsured.  This is far higher than the proportion of uninsured population in the general population, and speaks volumes about the perils of being uninsured.  Beth points out that the Children’s Health Insurance Program (SCHIP) was in effect for the second half of the study, and yet there are still seven million uninsured children in the US (nearly 170,000 of them are here in Colorado).

POLITICS AND HEALTH CARE REFORM:

InsureBlog’s Hank Stern wrote about a recent blogger teleconference with Rep. Joe Wilson, for a glimpse at a right wing Representative’s take on all things health care.

Mad Kane has written a limerick for Fox News and a limerick for Joe Lieberman. I don’t think she’s particularly fond of either of them.

My Wealth Builder has an article about why the government isn’t fit to run our health care system.  I think most of us agree that the income tax system is way too complicated, and that some government programs could be run more efficiently.  But indeed there are plenty of people who believe that Medicare is a good example of a well-run health care system that could be a model for providing care for the rest of the population.

Chris Langston, writing at the John A Hartford Blog, has drafted a “Declaration of Innovation” (modeled on the Declaration of Independence) pertaining to health care.  He’s primarily focused on geriatric care and health care for an aging population, but his words are appropriate for health care in general.

Tinker Ready, of Boston Health News, writes about the relationship between medical academics/doctors and the medical industry (think: “consulting” fees for docs, vacations to exotic destinations sponsored by drug companies, speaking fees for medical professors, etc.).  Part of the health care reform bill includes long-overdue “sunshine provisions” intended to increase transparency when it comes to the relationship between doctors and industry.

INFORMATION TECHNOLOGY:

Healthcare Technology News brings us an article about provisions in the House health care reform bill that would eliminated a lot of the complexity and frustrations that go along with our current (non-electronic) health care reimbursement system.  Real time determination of a patient’s financial responsibility for a service, either before the procedure is scheduled, or at the time of service, would be a huge improvement over our current system of waiting for the bills to arrive with only a sketchy idea of how much they will be.  In general, the adoption of an electronic and standardized health care administration system is a definite positive in the House bill.

David Kibbe, writing at the Health Care Blog, details the importance of a Continuity of Care Record for every patient, ideally in an electronic, easily accessible format.  Allowing doctors and nurses to see at a glance a patient’s health history, allergies, medications, and basic vitals would eliminated the need for redundant testing (a cost-saving plus), and would enhance decision making when it comes to current care.  David points out that while most of our health data is currently being entered into a computer somewhere, it tends to be in disparate systems that aren’t easily compiled into one continuous record for each patient.

Elyse at AntiClue has written an article about the various technologies available to help reduce the incidence of adverse drug effects.

EVERYTHING ELSE:

Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon NH, puts a personal face on advance directives in an article that should encourage all of us to add an advance directive to our to-do lists.  As he says, “you don’t have to be dying for these discussions to matter.  You just have to be mortal.”

Workers’ Comp Insider’s Julie Ferguson brings us an article about the largest fine ever levied by OSHA – $87 million in penalties – directed at BP for a refinery explosion four years ago that killed 15 people and injured 170.  Incidentally, the second-largest fine they ever levied was also against BP, related to the same explosion.  BP is contesting the fine, saying that it is an example of big government intruding on private business.  Without knowing anything more about the situation than what I just read in Julie’s article, my bet would be that BP is probably more concerned about profits than they are about the health and safety of their workers.

Susan DeVore, CEO of the Premier Healthcare Alliance, writes about the collaborative efforts of 157 hospitals working together to improve patient outcomes and control costs through a program called QUEST (Quality, Efficiency, Safety, and Transparency).  The hospitals shared data and information with each other, and after a year the hospitals had 14% fewer deaths than expected, and had saved $577 million.  Systems like QUEST, implemented throughout the country, encouraging collaboration and transparency among all hospitals could result in even more impressive results.

But while hospital collaboration can produce better outcomes and save money, we don’t want to take a good thing too far, as hospital mergers are a factor in driving up health care costs.  Ken Terry, writing at BNET explains how costs have grown much faster than usual over the past decade, following a period of unprecedented hospital mergers that resulted in much less competition between hospitals in most metro areas.

Amer at Healthcare Hacks tells us about the FDA’s Emergency Use Authorization for Peramivir, a drug that can be used to treat H1N1 – without the normal extensive trials that drugs must go through in order to be approved.  He also throws in a reminder about hand washing, since prevention is always the best strategy.

While we’re on the topic of H1N1 treatment, Eric Turkewitz has an interesting article about drug wholesalers trying to peddle flu vaccine for eight times the normal price, while also refusing to say where the vaccine originated.

Thanks to everyone who submitted articles; it was a pleasure reading them.

Optional theme, because of the upcoming Thanksgiving holiday, will be articles about something you’re thankful for.

The theme is optional. Grand Rounds will include all other important topics you write about. Looking forward a thankful edition!

Insurance carriers in Colorado were strongly opposed to HB1355.  The majority of small businesses in Colorado were receiving a discount on premiums based on health status, which HB1355 forbids.  Insurers knew that businesses that were already struggling to pay premiums at a reduced rate might decide to forgo health insurance for their employees after the discount was eliminated.  This is especially true for the most healthy groups, whose members can find health insurance within the medically underwritten (and less expensive) individual market.  Of course the removal of healthy groups from the pool of insureds only serves to drive premiums even higher for the sicker groups who remain insured under the group plans.  It’s true that groups can no longer be rated higher than the base rate because of the specific health of the group, but the base rate can – and likely will – continue to rise.

Critics are questioning why insurers keep bringing up HB1355, as the trend in national health care reform these days is towards guaranteed issue health insurance without underwriting – which is what HB 1355 was all about.  But while HB1355 was beneficial to groups with unhealthy members, the majority of small groups in Colorado had a discount before HB1355 took effect.  And if those groups are unable to afford their new, higher rates, they can opt to cancel their coverage – which leads to higher prices for groups that remain covered.  On a national level, as far as individual health insurance is concerned, HB1355 should be considered a warning sign.  Getting rid of medical underwriting is the right, and fair, thing to do.  But not if people can come and go as they please in the insurance system.  We’ve seen what the impact will be on premiums if guaranteed issue coverage takes effect without a strong mandate requiring people to carry health insurance.  I think this is why insurers are still bringing up HB1355.  It’s impacting all small groups in Colorado now – there’s no more putting it off.  And significant rate hikes for healthy groups should serve as a warning for what we’ll likely see in the individual market if reform passes without a way to make sure that everyone is part of the insurance pool.

The good news is that the 11.8% rate hike is the lowest percentage increase Colorado businesses have seen in this decade (the next lowest were in 2000 and 2005, when rates jumped by 12%).  So while the increase is higher than the national average, perhaps it’s headed in the right direction.  Maybe one of these years, we’ll see a single digit rate increase.

Colorado residents tend to be healthier than the average American.  We’re thinner, and have lower incidence of hypertension and diabetes than most of the rest of the country.  So why would health insurance rates be rising faster here than in the rest of the country?  My guess is that it has something to do our higher-than-average percentage of the population without health insurance.  17.2% of Colorado residents are uninsured, compared with national numbers that tend to be in the 15 – 16% range.  When uninsured patients are treated by our health care providers (emergency rooms are a good example of this), the providers have to recoup their losses somehow.  This usually translates into higher reimbursement rates being negotiated with health insurance companies.  The insurance companies pass on their higher costs to customers in the form of higher premiums and/or reduced benefits.

Since Colorado has a higher percentage of the population without health insurance than the country as a whole, I imagine this has to have something to do with our health insurance premiums rising faster than the rest of the country.  Unfortunately, this is a self-perpetuating cycle: higher premiums mean that more businesses drop their health insurance policies, leading to more uninsured people, which leads to higher premiums for the people who still have coverage.  Not a good scenario, any way you look at it.

Of course, the question remains as to whether or not a public option would actually cause private health insurance premiums to rise more quickly than they already do.  David Williams believes that it would not, and has detailed several reasons for this in his article, which is well worth reading.

I found David’s article in Grand Rounds, hosted this week at Non-Clinical Jobs.

Specifically forbidding the practice of denying coverage to domestic violence victims is also part of the House bill, and will likely receive widespread support from both women and men alike.  But in the eight years since we started selling medically underwritten health insurance, I can’t remember a single time that an applicant was declined for being a victim of domestic violence, nor have I ever seen a question on any application asking if the applicant has been abused.  So while this provision makes sense, and will no doubt be beneficial for a few people, I imagine its strongest impact will be in helping to rid us of “blaming the victim” mentality.

The woman-friendly part of the House bill that will likely have the biggest impact on premiums is a provision that would require all plans in the health insurance exchanges – and eventually even plans outside of the exchanges – to cover maternity care.  While this sounds like a good idea in theory, it could have a significant impact on premiums.  If mandates requiring everyone to have health insurance are effective, and the pool of insureds grows to include the entire population, it will be easier to work maternity care into the cost of coverage.  But it remains to be seen how effective the mandate will be.  In Colorado, there are only a few individual health insurance policies that offer maternity coverage as an optional benefit – and they do so at a pretty high price.  The premium is high because the only people who add maternity coverage to their policies are people who intend to use the coverage.  Having maternity coverage on all policies – whether a person intends to use the coverage or not – would spread the cost, but the net result would likely be an overall increase in premiums.  I’m curious as to whether anyone has crunched the numbers and calculated how much premiums will increase if this provision becomes law.  I’m also curious as to whether people like Jay and myself, who choose to have a homebirth with a licensed midwife, would still have to pay for our maternity care out of pocket, while also paying for maternity coverage (that we wouldn’t use) as part of our health insurance premiums.  And most of all, I’m curious about whether this addition to the House bill was tacked on because it makes good financial sense for the overall population, or because it’s a feel-good provision that will help to sway the female vote.

In 2007, the Lewin Group released a report for the Colorado Blue Ribbon Commission for Health Reform.  It showed that 38.7% of Colorado residents age 19 – 24 were uninsured.  This was far more than the next highest category (27.1% of people age 25 – 34 were uninsured).  Several factors contribute to the high percentage of young people who are uninsured.  They tend to be healthy, and thus aren’t as likely to see the value in health insurance.  They tend to work in entry-level jobs that aren’t as likely to provide health insurance benefits.  And they usually have lower incomes than older workers, making health insurance – even if it is cheaper for them – harder to afford.

Various committees in congress have proposed reforms that limit premiums for older Americans to two, three, or four times the cost of premiums for younger people.  One way or another, health insurance companies have to take in enough in premiums to cover the cost of claims for the entire insured population.  If the amount that can be charged for older insureds is limited to twice the cost of premiums for younger people, it makes sense that premiums for younger people will rise substantially above where they are now.  Given the large number of uninsured young people – many of whom cite cost as a major factor in their lack of coverage – it seems that dramatic increases in premiums for this demographic will be counterproductive.  Especially if the mandate requiring everyone to have health insurance remains weak.

In order for the health insurance system to function well, and really spread risk across the whole population, we need to make sure that young, healthy people are insured.  And to do that, we have to make sure that premiums are affordable for them.  People who are sick, and people who are older and more likely to have chronic health conditions, already see the value in health insurance, and will work to fit it into their budget.  Young, healthy people might not have as much motivation to budget for health insurance.  And if the premiums skyrocket, they will be even less likely to obtain coverage.  We need to work on long-term solutions for lowering health care costs for everyone.  But in the beginning, we need to make sure that young, healthy individuals aren’t facing health insurance premiums that are dramatically higher than the current premiums that they struggle to afford.