More money for community health centers. Immediate help for the uninsured. No more lifetime limits on coverage.
Under the health care legislation that’s moving through Congress, these and other benefits would take effect quickly and should produce a noticeable impact on consumers, according to many independent analysts and Democrats.
“This would be a substantial package that could probably be quite helpful,” said John Holahan, the director of the health policy center at Washington’s Urban Institute, a research group.
Paul Ginsburg, the president of the Center for Studying Health System Change, called help for Medicare prescription-drug beneficiaries and people with pre-existing medical conditions “highly visible improvements for individuals already highly aware of the shortcomings of the existing system.”
The insurance industry sees potential trouble, however. “These provisions have the potential to cause significant disruption for individuals and families in the years before the full benefits kick in,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the industry trade group.
Republicans have other beefs, saying that had many of these measures been the crux of the health care legislation – instead of a relatively small piece of more ambitious legislation – the debate and voting would have been over by now.
“What Republicans have always said is that 75 to 80 percent of the items we agree on,” said Brian Walsh, a spokesman for the National Republican Senatorial Committee, without endorsing any specifics.
The sticking points include provisions that allow certain tax increases to start next year as well as longer-range changes such as a government-run plan or mandating that nearly everyone obtain coverage, provisions that wouldn’t take effect until 2013 or 2014.
Leaders in the House of Representatives and the Senate are expected to reach agreement on the legislation in the next few weeks, with the aim of having a final bill ready for President Barack Obama’s signature later this month.
The two bills have several similar immediate-impact features. Both would bar lifetime limits on coverage, starting six months after the measure is enacted.
They also would expand community health centers, where consumers could go for care, and would require health plans to allow young people, up to age 26 in the Senate bill and 27 in the House bill, to stay on their parents’ policies. Age requirements now vary by state.
Both bills provide immediate aid for the uninsured. The Senate would provide $5 billion to help finance a temporary program that would provide coverage to uninsured people with pre-existing conditions, effective 90 days after the bill is signed.
The House bill also would create a temporary insurance program for those who have trouble getting coverage, effective immediately upon passage.
“In general it’s a good idea,” Holahan said, “but how much would people pay to get into it? There are so many questions we don’t know the answer to.” Those questions presumably will be resolved in upcoming House-Senate Democratic negotiations.
Zirkelbach of the insurance group noted that many states have their own high-risk pools, so a federal program could be duplicative. He also questioned whether the federal funding would be adequate to help pay for the cost of care.
The steps that both houses of Congress want to take to close the Medicare prescription-drug coverage gap, or “doughnut hole,” are clearer. This year, Medicare prescription-drug beneficiaries who don’t receive the program’s low-income subsidy or who aren’t enrolled in drug plans that provide “gap” coverage must pay the full prices of their drugs once expenditures by their plans and them total $2,830.
Then, once a beneficiary’s out-of-pocket costs for the year total $4,550, Medicare catastrophic coverage kicks in and the beneficiary pays only a small co-payment for each drug until the end of the year. The $2,830 figure doesn’t include the plan’s monthly premium, which the beneficiary must continue to pay even while in the coverage gap.
Both bills would shrink the gap by $500 immediately, and would provide 50 percent discounts on brand name prescriptions for most recipients.
The Senate bill has other provisions. After 2014, insurers couldn’t reject anyone because of pre-existing conditions, and the bill would bar companies from turning down any children beginning six months after enactment.
It also would allow small businesses, generally those with fewer than 25 workers, to get tax breaks, beginning this year, if they help their employees buy coverage.
The biggest controversy – one that’s likely to be the subject of debate in coming weeks – is the requirement that insurers spend 80 to 85 percent of premiums on care, starting almost immediately.
The change could have a dramatic impact on coverage now purchased by about 17 million people who buy privately because they choose to do so or aren’t offered plans through their employers, Zirkelbach said. He called the 80-85 percent figure arbitrary, and said it “does not take into account the higher structural costs” in the individual market.
Further, since the health insurance exchanges, or marketplaces that help consumers shop for coverage, wouldn’t be up and running for several years, people “would have nowhere to go,” he argued, “and their coverage could be disrupted significantly.”