Health Reform Update - 3/24/10

There’s been plenty of talk recently about what the health reform bill will mean for Americans. Today, we want to focus on the 10 best immediate benefits that health care reform will have for everyone. These are just a few of the changes that are incorporated into the house bill, and they include the provisions that the Senate is currently voting on.

1) Small business tax credits.
• Tax credits of up to 35% of premiums are immediately available to small businesses that offer coverage. In 2014, these credits will increase to offset 50% of the cost.
2) Closing the Medicare Part D Donut Hole
• All Medicare enrollees that hit the donut hole this year will receive a $250 rebate. Beginning next year, brand-name drugs will be discounted by 50% in the donut hole. By 2020, the donut hole will be completely closed.
3) Free preventative care
• Beginning January 1, 2011, there will be no copays or deductibles for any preventive services paid for by Medicare.
• Starting in 6 months, all new private plans will be required to offer preventive services without charging copays or deductibles.
4) Ending recissions
• Starting in 6 months, health insurance companies will no longer be allowed to drop people when they get sick.
5) No lifetime or annual limits on coverage
• Starting in 6 months, insurance companies will not be allowed to place lifetime limits on benefits.
• Beginning in 6 months, new regulations would restrict the use of annual benefit limits to deny services to patients. In 2014, annual limits would be banned from all new plans.
6) No discrimination against children with pre-existing conditions
• In 6 months, insurance companies will be banned from denying coverage to children based on pre-existing conditions. In 2014, this rule will be applied to people of all ages.
7) New appeals process
• Creates a new and effective internal and external appellate process to allow a patient the opportunity to challenge decisions made by his or her insurer.
8) Premiums must go towards paying for care
• Starting January 1, 2011, all large-group market insurers must spend at least 85% of the cost of premiums on providing actual care. Insurers that cover individuals or small groups must use at least 80% of premiums to pay for care. Companies that don’t do this will have to refund their policyholders.
9) Immediate creation of a high-risk pool
• In 90 days, a temporary subsidized “high-risk pool” will open for people who cannot get insurance due to pre-existing conditions. This pool will close once the exchange opens and insurance companies are banned from denying coverage to adults (in 2014).
10) Health insurance consumer information
• Provides immediate funding to state governments to create programs that will help patients learn their rights and file complaints and appeals when care is denied.

Health Care Story of the Week - 3/17/10

Laurenda is the adoptive Mom of six girls, including 12 year old Karla and her sister. In 2003, she and her husband, Danny, took Karla in as a foster child. Karla needed to have open heart surgery, and after negotiating with Karla’s birth mother, Laurenda received permission to get heart surgery for Karla.

Laurenda made sure that Karla made it to all of her appointments with the cardiologist and the surgeon, as well as all her other doctors. When Karla went to Vanderbilt for surgery, Laurenda stayed there with her for a week. “She played games with me and even pulled me up and down the halls in a red wagon,” said Karla. “My new Mom even made a scrapbook for me of my time in the hospital so I would always know why I have scars on my chest.”

Thanks to Laurenda’s dedication, Karla’s surgery was a success. Now, “You can’t tell Karla that she can’t do anything,” said Ms. Whisenhunt. “She loves to work with my husband building things. She doesn’t have the fear of overdoing something, she has confidence.”

All of Laurenda and Danny’s adopted daughters have special needs, “but she always manages to take care of us,” said Karla. “I can’t really think of the words to tell you how special she is… All of my friends think she is the bomb.” As this family's story demonstrates, a parent's persistence and dedication to ensure that her children get the care they need can make all the difference.

Health Care Story of the Week - 3/11/10

This week, instead of telling the story of one family, we'd like to share information about the state of health care in Tennessee as a whole. The following information comes from Families USA. More info on all states can be found at http://www.familiesusa.org/health-reform-2010/cost-of-doing-nothing.html.

1. If we don’t pass health reform now, 158,000 Tennesseans will lose health insurance by 2019. 

• If we do nothing, 1,065,000 Tennesseans will lack health insurance by 2019, leaving 1,065,000 people with few options when they get sick.
• If Congress does the right thing and passes health reform, 611,000 Tennesseans will gain coverage.

2. If we don’t pass health reform now, the average Tennessean’s family insurance premium will increase by $7,737 by 2019.

• These increases in family premiums happen at a time of record-breaking profits for health insurance companies. The five biggest for-profit health insurers saw a combined $12.2 billion in profits in 2009.
• Passing health reform will provide subsidies to millions of Americans in order to make health insurance affordable. Health reform will also hold insurance companies accountable to their policyholders and not just their stockholders by requiring insurers to spend 85 cents of every dollar on actual health care.

3. If we don’t pass health reform now, more Tennesseans—our parents, our friends, our neighbors—will die because they lack health insurance.

• Nearly 13 working-age Tennesseans die each week because they lack health insurance.
• Health reform will expand life-saving coverage to thousands of Tennessee families.

4. If we don’t pass health reform now, Tennessee’s small businesses will pay $2.8 billion more for health care premiums by 2018, stifling innovation and job growth. 

• While Tennessee’s small businesses spent $2.1 billion on health care premiums in 2008, that number will rise precipitously to $4.9 billion by 2018 without health reform.
• By passing health reform, Congress will provide tax credits and a new marketplace for small businesses to provide quality, affordable coverage to their employees.

5. If we don’t pass health reform now, 177,000 Medicare beneficiaries in Tennessee will continue to hit the “doughnut hole,” or gap in Medicare Part D drug coverage.

• The doughnut hole costs seniors an average of $4,080 per year. 
• Health reform will reduce the doughnut hole, ensuring that Tennessee’s Medicare enrollees will not have to choose between food or medicine.

Health Care Story of the Week - 3/4/10

John and Sue have spent the last 20 years helping their son Jonathan reach his maximum potential. Jonathan suffers from Asperger’s Syndrome. This means that when medicated Jonathan has a nearly normal IQ but suffers from many of the debilitating characteristics of Autism. His disability prevents him from being able to socialize with other people and make sound decisions. At the age of 24, he has the functional IQ and emotional maturity of a young boy.

Sue, a BS Home Economist and certified teacher, gave up her career and dedicated herself to taking care of Jonathan. When Jonathan completed secondary school at age 20, John and Sue began searching for a long-term solution for Jonathan. They had heard about a special Medicaid waiver for the mentally retarded, but were then told that Jonathan did not qualify because of his normal IQ.

John and Sue then heard about a vocational rehabilitation program for people with neurological problems. They were then told that Jonathan did not qualify for that program because his functional level was too low.

John and Sue were determined that Jonathan was not going to fall through the cracks created by the bureaucracy of narrowly defined government programs. They did not give up.

The family eventually learned of a residential treatment facility that could treat Jonathan’s behavioral problems and improve his social functioning. They asked TennCare to pay for this treatment in the hopes that Jonathan would be able to go from the treatment facility to a group living environment. Without it, he would never make it in that type of living arrangement.

TennCare refused to pay for the treatment. The family appealed. They found a pro bono attorney to help them with the appeal. That attorney contacted TJC for advice on how to handle the appeal. TJC helped the attorney, and the John and Sue were able to get Jonathan the treatment that he needed.

The story does not end there, however. Despite the fact that Jonathan’s doctors do not think that he is ready to leave residential treatment, TennCare has repeatedly tried to stop paying for Jonathan’s care at the residential treatment facility. John and Sue are persistent and keep appealing to make sure that Jonathan receives treatment for as long as he needs it.

John and Sue are also still tirelessly searching for a long-term placement that will meet Jonathan’s needs, but will keep him in the community once he is ready to leave the residential treatment facility. Jonathan cannot be left unsupervised for his own safety and the safety of others. Finding a place for him to go after he finishes residential treatment when there seems to be no place for him to go is the next mountain that John and Sue are climbing to help their son.