Rate Review YES!

Illinois consumers want more control, stronger protections, and greater transparency in the insurance process. Rate review provides just that. It means that insurance companies will now have to prove the need to charge their customers more, and will not be allowed to do so unless they meet strict criteria.

Insurance companies will have to justify their requests for rate increases to the state Department of Insurance, and they cannot raise your rates unless their request is found to be reasonable and justifiable. The state Department of Insurance will act as a watchdog to ensure that rate increases are fair, needed, and enacted in accordance with the rules. That is strong protection for insurance consumers in Illinois.

The process is fair for both insurance companies and insurance consumers. Rates cannot be raised unless the review says they can, but insurance companies whose increases are denied, or consumers who disagree with a decision to allow rate increases, will have the opportunity to appeal the decision.

With more information about the rationale for rate hikes, consumers will be better prepared to make an informed decision about whether or not to purchase insurance from a specific company. This will stimulate positive competition in the health insurance marketplace, and benefit consumers by lowering costs.

Without rate review, health insurance premiums in Illinois rose 73% from 2000-2007. The rate review process will slow down sudden exorbitant cost increases for insurance, allowing all health insurance consumers including working families and small business owners the ability to obtain quality, affordable insurance for themselves and their families.

Health care reform is the key to economic security and opportunity for American families. Rate review is just one of the ways we will make the system more fair for everyone.

-- Jim Duffett, Campaign for Better Health Care

Top Ten Health Care Reform Terms You Should Know (but were afraid to ask...).

On March 23, 2011, we will be celebrating the one year anniversary of the Affordable Care Act (ACA). Although we at Health & Disability Advocates are in the thick of ACA implementation, we know that many Illinoisans still are confused about the law. In fact, according to a recent Kaiser Tracking Poll, just over one in five Americans (22 percent) think that the law has been repealed. It has not, and many provisions are already in place and working. In honor of the one-year anniversary of the law, we have compiled the Top Ten Health Care Reform Terms You Should Know (but were afraid to ask...).

See our list below. If you have questions about how these and other "terms" will affect you now or in the years to come, submit your question to Illinois Health Matters (where it says "Get Answers") and our team of experts will answer it for you.

1. Affordable Care Act (or ACA) – a short name for the Patient Protection and Affordable Care Act of 2010 which is the federal health care reform bill which passed Congress and was signed into law by President Obama. Some provisions went into effect immediately on March 23, 2010 and others will be phased in for the next 8 years. On March 1, 2011, the Illinois Health Care Reform Implementation Council presented a report to Governor Quinn with their initial recommendations for implementation of the ACA in Illinois.
2. Accountable Care Organizations (ACOs) – a group of health care providers such as physicians, hospitals or clinics that have entered into a formal arrangement to assume collective responsibility and financial risk for the care of a specific group of patients and receive financial incentives to improve the quality and efficiency of health care. You are not alone if you are uncertain about what an ACO actually looks like (see this recent article in Politico). The Centers for Medicare & Medicaid Services Administrator Don Berwick said in a speech earlier this week that the pending rules on ACOs will be out soon.
3. Essential Health Benefits – This is the minimum level of coverage that must be offered by qualified health plans operating in state health insurance exchanges. Essential benefits are defined in relation to the classes of services and benefits covered, the level of financial protection against deductibles, and cost-sharing protection they provide. The ACA lists ten categories that HHS must include as essential, such as prescription drug coverage and emergency hospitalizations. But HHS has broad discretion within those categories to require generous coverage or allow limits. Health care policymakers and medical experts at the Institute of Medicine are studying this issue and will make recommendations on the criteria and methods for determining the essential health benefits package.
4. Health Care Exchange (sometimes called Health Insurance Exchange (HIE) or Health Benefits Exchange) – a competitive health insurance marketplace for individuals and small employers to purchase insurance or enroll in Medicaid after 1/1/2014. Exchanges will be an easy-to-use website, similar to Travelocity or Consumer Reports. They will be responsible for calculating premiums, enrollment, quality oversight, and certification of qualified health plans. By standardizing health insurance products, enrollment, operations, and oversight, exchanges are also meant to make the process of selecting insurance easier, less expensive and more transparent. The site will be closely monitored to prevent fraud and protect consumers. Members of Congress will be required to get their insurance through this marketplace—giving them the same options as millions of Americans. The Illinois Department of Insurance has established workgroups to solicit feedback from stakeholders regarding how an exchange should function in Illinois. A piece of legislation will be introduced soon in the Illinois General Assembly to establish the Illinois Health Benefits Exchange.
5. Health Information Technology (sometimes called Health Information Exchange (HIE) or Electronic Health Records) – Technology that allows the management of health information such as health records, laboratory tests, and radiology records, to be communicated electronically among health professionals, consumers, health care providers, health care payers, and public health agencies. A new study completed by the Office of the National Coordinator for Health Information Technology and published in the journal Health Affairs this week finds growing evidence of the benefits of Health Information Technology on key aspects of care including quality and efficiency of healthcare. In February 2010, Governor Quinn established the Illinois Office of Health Information Technology which developed a strategic plan for Health Information Exchange in Illinois.
6. High-risk pools – High-risk pools are operated by states during the period prior to the implementation of health insurance Exchanges in 2014 as a means of offering health insurance to individuals who otherwise cannot buy health insurance in the individual market because they have a pre-existing health condition. Illinois' federally funded high risk pool, established by the ACA, is called the Illinois Pre-Existing Condition Insurance Plan (IPXP). Illinois also has another high risk pool called the Illinois Comprehensive Health Insurance Plan, which is not federally funded and existed before ACA, but it serves a similar function.
7. Individual Responsibility (also called the Individual Mandate) – this is the term that refers to the requirement in the ACA that by January 1, 2014, individuals must purchase insurance if they are not otherwise covered by public programs or group health insurance.
8. Maintenance of Effort (MOE) – The ACA includes an important protection that prohibits states from reducing their Medicaid eligibility levels or changing the rules to make it harder for people to enroll in Medicaid. This protection is referred to as the “maintenance of effort,” or MOE, requirement.
9. Meaningful Use – this is a yet to be determined critical level of use of electronic health records (EHRs) and related technology within a healthcare organization to deliver coordinated and quality health care to patients. Through the ACA, Medicaid and Medicare will require that providers increasingly utilize "meaningful use" health information technology in their practice in order to receive reimbursement. If you are a health care provider in Illinois and you have questions about meaningful use incentive payments, visit the State of Illinois' Electronic Health Records page here.
10. Medical Loss Ratio – A medical loss ratio (MLR) is the proportion of premium dollars that an insurer spends on health care services and certain recognized plan administration costs relative to health insurance premium paid by subscribers. The ACA requires health insurers offering health insurance coverage in either the group or individual (non-group) market to submit an annual report to the Secretary of Health and Human Services on their MLR and to provide rebates in circumstances in which losses exceed permissible levels (80% in the individual market and 85% in the group market). Illinois State Senator Heather Steans has proposed a bill, SB 1618, which would bring Illinois law into conformity with this core consumer protection established by the ACA.

For more terms and definitions, see http://www.healthreformgps.org/glossary and http://www.healthcareandyou.org/glossary/.

Stephanie Altman and Stephani Becker
Health & Disability Advocates

STAND UP FOR WHAT IS RIGHT! March 23, 2011 Rally to Celebrate the One Year Anniversary of the Affordable Care Act

Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection.

These were the words of President Harry Truman when he sent a message to Congress on the need for national health care.  He delivered his message on November 19, 1945.  It took sixty-five years for President Truman’s words to ring true with President Barack Obama’s historic signing of the Affordable Care Act (ACA) on March 23, 2010.

On the evening of March 23, 2011 at the Chicago Temple,  77 Washington, from 6:00-7:30 PM we will join together for a rally in celebration of  the one year anniversary of the ACA.  Hundreds of healthcare activists and leaders such as Congresswoman Jan Schakowsky, Governor Pat Quinn, State Representatives Greg Harris and Lou Lang, Keith Kelleher of SEIU Illinois/Indiana Healthcare, William McNary of Citizen Action/Illlinois, will come together to commit to the important work ahead of us.

We must fight to make Illinois a leader in creating a strong, transparent Health Benefits Exchange that will maximize the ability of individuals and small businesses to access the best insurance at the most competitive price.  We must fight to support strong consumer protections against excessive premium increases for health insurance in Illinois.

And we will celebrate the success of the ACA and its impact on Illinois.  One year after the signing of the law millions of Illinoisans are already reaping the benefits:

• 1.8 million seniors will receive free wellness visits
• 109,000 seniors already received prescription drug rebates
• 47,000 young adults under 26 can stay on their parents’ insurance
• 612,000 Illinoisans no longer have to fear losing their insurance
• 3,000 Illinoisans with pre-existing conditions have access to insurance with the Illinois Pre-Existing Condition Plan (IPXP) 
  

While we celebrate our victories we know that our fight is far from over.  We are already witnessing the entrenched power of the insurance industry’s impact on pro-consumer legislation that is making its way through Springfield.  The forces that want to fight for the status quo are attempting to stop our progress.  This consummate struggle has raged in our country for a century. 

On March 23, 2010, President Obama dedicated the signing of the bill to his mother, who was forced to argue with insurance companies while she was dying of cancer.  It would heed us well at this critical time in the implementation of the law to remember President Obama’s words at its signing: 

We are not a nation that scales back its aspiration. We don’t fall prey to fear...we are not a nation that does things that are easy. We are a nation that does what is hard, what is necessary, what is right.

Stand up for what is right!   Join us to rally for healthcare on March 23, 2011.

Lynda DeLaforgue
Co-Director
Citizen Action/Illinois

Out-of-Pocket Spending Caps Protect Families in Illinois

March 23, 2011 marks the one year anniversary of the Affordable Care Act (ACA), landmark legislation in the fight to ensure quality affordable health care for all Americans. To celebrate this milestone, the Campaign for Better Health Care and the Health Care Justice Campaign have announced that March is Health Care Justice Month in Illinois.

"We want to look back at the new benefits that are already helping Illinois' working families and look ahead to the benefits that are yet to come," said Jim Duffett, Executive Director of the Campaign for Better Health Care (CBHC). "It is amazing that so many Illinoisans are already experiencing a positive impact from this law, and inspiring to realize how many more will in the near future."

To kick off Health Care Justice Month, CBHC co-released a report by Families USA examining how the health care spending caps in the ACA will positively affect Illinois families. The health care cost cap provision does not kick in until 2014, but until it does, the resulting analysis for Illinois spotlights the tremendous need for spending caps to protect family budgets:

• In 2011, 590,500 Illinoisans under the age of 65 are in families that will spend more than the out-of-pocket caps for services that will be covered in the Affordable Care Acts essential benefits package.
• The Affordable Care Act spending caps, when adjusted to 2011, would be $5,950 for individuals and $11,900 for families. Out-of-pocket health care spending by these Illinois families will exceed the caps by more than $1.0 billion in one year alone.

Health Care Justice Month will feature online activities like a poll on the benefits of the Affordable Care Act and events across the state, including a postcard campaign, a series of Minority Health Care Roundtable discussions, and the Campaign for Better Health Care Faith Caucus' annual Sound the Alarm Sabbath weekend. During Sound the Alarm, congregations of all faith traditions reflect upon the moral imperative of health care reform, and sound a traditional musical instrument 18 times to mark Illinois' 1.8 million uninsured.

The Families USA report, Worry Less, Spend Less: Out-of-Pocket Spending Caps Protect Families in Illinois, found that more than nearly three-quarters (71.7%) of the Illinoisans who will spend more than the out-of-pocket caps an estimated 423,700 people are in working families.

John Bouman, President of the Sargent Shriver National Center on Poverty Law said, "As demonstrated by Families USA's excellent report, the caps on families' out of pocket health care spending that will go into place under the ACA in 2014 will be extremely important to the financial well-being of working families and small businesses."

In particular, employees of Illinois small businesses, those with fewer than 100 employees, face the threat of high out-of pocket health care spending:

• An estimated 239,500 Illinoisans in families where the head of the household is employed by a small business will spend more than the out-of-pocket caps.
• More than two in five Illinoisans (40.6%) who will spend more than the out-of-pocket caps are in families where the head of the household works for a small business.
• Of those Illinoisans in families of small business workers, more than four-fifths (82.0%) have a head of household who works for a business with fewer than 25 employees.
• Families of Illinois small business employees will spend nearly $414.0 million more than the out-of-pocket caps in 2011 alone.

Janine Lewis, Executive Director of the Illinois Maternal and Child Health Coalition, added, "We applaud these caps which will help women and children afford access to critical health services to keep themselves and their families healthy."

"Two decades of rising health care costs have squeezed families into coverage with higher premiums, higher copayments, and higher deductibles, and sometimes these costs have forced families out of health coverage altogether," Ron Pollack, Executive Director of Families USA, said. "These families are terribly vulnerable to financial devastation caused by unexpected illness or injury, and they generally face only bad alternatives, including massive credit card debt, bankruptcy, even foreclosure."

"The report from Families USA clearly shows that 590,500 Illinoisans, and nearly 15 million people across the nation, will deal with this kind of health and financial crisis this year alone. The caps on out-of-pocket spending that will be put in place by the Affordable Care Act will have a profound, beneficial impact on the fortunes, finances, and futures of families in Illinois."

Pollack noted that between 2000 and 2010, the average premium for job-based family coverage grew from $6,438 to $13,770, an increase of 114 percent. These increases have been a special burden for small businesses, which, because of lower buying power and proportionately greater administrative costs, pay, on average, 18 percent more than large businesses for a comparable health insurance plan.

"These caps will be of special value to small businesses and the employees of small businesses," Pollack said.

The spending cap provision of the Affordable Care Act includes a sliding scale that will ensure those with lower and middle incomes will pay less out of pocket than those with higher incomes. "Access to affordable health coverage is the key to economic security and opportunity for the working families and small businesses of Illinois," said Jim Duffett. "This provision of the Affordable Care Act ensures that they will now be able to get a fair deal."

-- Kathleen Duffy, Campaign for Better Health Care

Top 10 List of Exciting Opportunities Available Through Health Reform

With the passing of the Patient Protection and Affordable Care Act one year ago, health professionals and consumers – providers, researchers, policy leaders, advocates, administrators, and others – have been coming together to determine the best way to implement the new health reform law. While no one person or group has the complete answer, we are moving ahead with reform.

I’ve had the chance to attend a few conferences related to health reform implementation and have learned a lot about our health system in that process. I’ve learned that nobody really knows what an Accountable Care Organization is (something the law encourages), but that most people want to create one. I’ve learned that our health system is more fragmented than I could have imagined, but that everyone agrees we should improve coordination. I’ve learned that the politics that seem to divide us are only making things worse. But most of all, I’ve learned that there are thousands of committed individuals who truly believe in reform and are dedicated to improving the quality and accessibility of healthcare for all.

While the conferences have left me with a renewed sense that single-payer health care is the best way to align our financial incentives to create the kind of health system we really want and need, I do think there are many promising aspects of this new law. Based on what I know so far, I have put together my top 10 list of exciting opportunities available through health reform:

1.) We now have a national, state, and local platform for discussing health reform and innovative strategies for improving health.

2.) There are many new opportunities for health information technology! Not only is there a push to get electronic medical records, but the Department of Health & Human Services has spearheaded a Community Health Data Initiative to bring innovated IT programs into the health data world. Check out http://health.data.gov, http://healthindicators.gov, and see the new Health IT Developer challenge at http://health2challenge.org.

3.) “Safety Net” health care providers (those who serve uninsured, Medicaid, and vulnerable populations) are struggling and may continue to struggle financially, but also offer the best hope for providing culturally competent health care to our diverse and expanding population.

4.) There are many incentives in health reform to create healthcare provider teams, expanding the roles of nurses, physician assistants, patient navigators, community health workers, social workers, dentists, physical therapists, primary and specialty physicians, and more! An interdisciplinary approach to providing healthcare will increase our capacity to meet the needs of our population, especially those who are newly insured.

5.) We have an increased focus on health care quality and the reduction of health disparities. The health reform law will set standards for data collection related to health disparities and there are many new incentives and initiatives to improve healthcare quality.

6.) Consumers will be better protected from excessive rate increases, rescissions, and limits on insurance company products. This will help more people get and keep health insurance.

7.) We have a real opportunity to transform the way we provide coordinated care. There are opportunities in health reform to develop creative models for medical homes and coordinated care, ensuring that patients received comprehensive, quality care that is coordinated between all care providers and locations. Perhaps some of these models will even extend to social services and transportation too.

8.) We can greatly expand job opportunities within the healthcare field. With more people accessing care and the need for an interdisciplinary and diverse workforce, there should be many new opportunities for people to find jobs and develop careers in health.

9.) Health reform has highlighted the need for an expanded primary care workforce. It will take time to develop this workforce, but the law puts new money into education and training of primary care providers.

10.) Finally, the obvious, millions more people will have health insurance, providing our best hope that they will seek preventive health services and care early on for illnesses, therefore creating a healthier public and ultimately saving money.

Janna Stansell, MPH
Policy Analyst
Health & Medicine Policy Research Group

What did the President Just Say??

On Monday, while addressing the nation's Governors, President Obama endorsed bipartisan legislation introduced by Sens. Wyden-Brown-Landrieu that speeds up the date by when states can apply for so-called "State Innovation Waivers" from 2017 to 2014.

Waivers come in many shapes and sizes and can be quite confusing. (Just watch the Members of the House Energy and Commerce Health Subcommittee try to wrap their heads around waivers at today's hearing if you need any convincing on that fact.) So the first point that needs to be made is that this is no "fait accompli".  Congress would have to enact legislation to amend the Affordable Care Act to change the date when these waivers become available. We don't know exactly how the Congressional Budget Office would score this, but The New York Times quoted a figure of $4 billion - not an insubstantial figure. And given that the House seems focused on a course of repeal not amend, it seems hard to imagine them coming up with any money to make a change which it seems like House leaders will reject as meaningless anyway.

What are State Innovation Waivers? State Innovations Waivers are a new, and at this point theoretical option.  They were created by the Affordable Care Act and currently the statute says they don't become available until 2017. State Innovation Waivers are not Medicaid and CHIP waivers but rather give states the opportunity to request a waiver of provisions of the new law related to exchanges, benefits and cost-sharing protections. A state could apply for this new waiver through a coordinated process with a Section 1115 Medicaid and/or CHIP waiver thus marrying the two into a "super waiver" proposal - hence some of the confusion.  But otherwise the Wyden-Brown-Landrieu legislation really doesn't impact the current Section 1115 Medicaid and CHIP waiver process.

Here is how a fact sheet from the White House accompanying the President's remarks describes State Innovation Waivers:

Under the Affordable Care Act, State Innovation Waivers allow States to propose and test alternative ways to meet the shared goals of making health insurance affordable and accessible to all Americans, including those living with pre-existing conditions.  Specifically, State Innovation Waivers are designed to allow States to implement policies that differ from the new law so long as they:

•  Provide coverage that is at least as comprehensive as the coverage offered through Exchanges - a new competitive, private health insurance marketplace.
•  Make coverage at least as affordable as it would have been through the Exchanges.
• Provide coverage to at least as many residents as the Affordable Care Act would have provided.
• Do not increase the Federal deficit.

The fact sheet goes on to say that the law also allows States to submit a single application that includes Medicaid waiver requests which could, for example, seek to give people eligible for Medicaid the choice of enrolling in Exchange plans. This line may have caused some more confusion because the Heritage Foundation, among others, has called for states to be allowed to move Medicaid beneficiaries into the exchange, receive federal tax credits in lieu of being Medicaid beneficiaries. But I don't think the Affordable Care Act allows that. What this statement means to me is that a state could choose to use exchange plans as a delivery system for Medicaid as long as Medicaid beneficiaries continued to receive the benefits and the cost-sharing protections for which they are eligible (in other words, as long as they remain Medicaid beneficiaries).

So the next step is to see whether Congress takes up this proposal.

Originally posted by Joan Alker on Say Ahhhh! A Children's Health Policy Blog

http://theccfblog.org/

Third Federal Judge Upholds Constitutionality of Affordable Care Act

On February 22, a federal district judge in the District of Columbia became the third federal judge to affirm constitutionality of the Patient Protection and Affordable Care Act, making the national scorecard 3-2 rulings in favor.

Judge Gladys Kessler dismissed the challenge to the individual mandate clause filed by five individuals representing the American Center for Law and Justice, a conservative legal group. The group argued that it is unconstitutional to require individuals to purchase health insurance and also claimed that the mandate is in conflict with their religious freedoms.

In her 64-page opinion, Judge Kessler "didn't mince words," writes Jonathan Cohn, health care writer and editor of the New Republic. The judge stated that the claim the law regulates "inactivity" is nothing more than semantics, saying:

"It is pure semantics to argue that an individual who makes a choice to forgo health insurance is not ‘acting,’ especially given the serious economic and health-related consequences to every individual of that choice. Making a choice is an affirmative action, whether one decides to do something or not do something. They are two sides of the same coin. To pretend otherwise is to ignore reality.”To date, three judges have upheld the law, thirteen federal district judges rejected lawsuits charging that the Affordable Care Act is unconstitutional, and two have ruled against it.

Judge Kessler also points out the decision to not obtain health insurance results in higher premiums for all those who do pay for coverage. Her ruling upholds the model of individual responsibility that is vital to the Affordable Care Act. It is incorrect to think that individuals, even those without insurance, are not already in the health care marketplace. They are.

In addition, Judge Kessler takes a strong stance against the "broccoli argument" posed by Judges Henry Hudson and Roger Vinson, who both ruled again the ACA. If Congress can make you purchase health insurance, they argue, why can't it make you buy broccoli or a certain kind of car? Kessler responds:

"This second aspect of the health care market distinguishes the ACA from Plaintiffs’ hypothetical scenario in which Congress enacts a law requiring individuals to purchase automobiles in an attempt to regulate the transportation market. Even assuming that all individuals require transportation in the same sense that all individuals require medical services, automobile manufacturers are not required by law to give cars to people who show up at their door in need of transportation but without the money to pay for it. Similarly, food and lodging are basic necessities, but the Court is not aware of any law requiring restaurants or hotels to provide either free of charge."

In short, she recognized that the insurance market is much different than other kinds of markets, and that the rules governing them must be adjusted accordingly. This is "critical to understanding the ACA’s efforts to reform the health care system," writes Cohn. "The requirement placed upon medical providers by federal law to care for the sick and injured without recompense is part of the cost-shifting problem that Congress sought to redress by enacting the ACA. When a supplier is obligated by law to produce goods or services for free, there is bound to be a substantial effect on market prices if consumers’ behavior results in that obligation’s frequent invocation."

The Affordable Care Act has already made a difference in the lives of millions of Illinoisans. Over 2.5 million state residents under the age of 65 who have pre-existing conditions will now be able to get health insurance. All of Illinois’s 1,770,000 seniors and people with disabilities on Medicare will no longer have to pay for preventive services, and many will have more help paying for prescriptions. In total, 1,163,000 uninsured Illinoisans will gain insurance coverage.

"Health care is the key to economic security and opportunity, and the Affordable Care Act is finally bringing fairness to the health care system for American families,” says Jim Duffett, executive director of Campaign for Better Health Care.

To date, three judges have upheld the law, thirteen federal district judges rejected lawsuits charging that the Affordable Care Act is unconstitutional, and two have ruled against it.

-- Kathleen Duffy, Campaign for Better Health Care