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.

Health Care Story of the Week - 2/24/10

Tamorra Clark is a 10 year old girl born with multiple medical problems, including cerebral palsy and developmental disabilities. As a result of these conditions, she requires private duty nursing at home to meet her medical needs. Tamorra’s parents both work in the army and are stationed in Tennessee. The army’s medical insurance covers half of Tamorra’s private duty nursing while TennCare covers the other half. In January, Tamorra’s mom received a notice from TennCare telling her that Tamorra was no longer eligible for TennCare services. She was told that Tamara’s eligibility category was closing and she did not fit in any others. This meant TennCare would no longer supplement her private duty nursing hours, and she would go without care for large portions of the day.


Tamorra’s parents were particularly upset about the impending loss of their daughter’s TennCare and home health care given their line of work. They are two people who have promised to give their lives for the protection of our country yet their daughter may have to go without her much-needed nursing care.

Tamorra’s mom, Ms. Quinn-Clark contacted TJC, worried that her daughter would not be taken care of; Ms. Quinn-Clark was scheduled to be deployed to Afghanistan at the end of January, and her husband, who works, would not be able to stay home to take care of Tamorra. TJC explained to her what her options were and told her about the MR waiver. The MR waiver is a statewide program to help individuals with mental disabilities. Enrollment on the waiver also entails coverage by TennCare. Ms. Quinn-Clark applied for the waiver services for her daughter and is waiting a decision.

Ms. Quinn-Clark has already deployed to Afghanistan, where she will remain for one year. In the meantime, her husband must balance his full time military obligations with caring for his daughter, all while worrying about what may happen if Tamorra is not able to enroll.

Health Care Story of the Week - 2/10/10

Judy’s adopted son, Ladontay, age 6, loves skateboarding, coloring, watching wrestling on TV, reading, and going to school. However, Ladontay has cysts on his nose that make wearing regular glasses painful. Judy knew that if Ladontay’s glasses were more comfortable, he would leave them on at school and be able to learn more easily. His doctor ordered special glasses; however, his TennCare vision plan would only cover non-flexible glasses. The law says that children should have what they need to meet their potential. The plan would not even explain to Ladontay’s grandmother why it was denying the glasses.


Frustrated, Judy called the Tennessee Justice Center for help. TJC called the vision plan, Judy called TennCare, and the two worked together to write a letter to the state’s attorneys. Within three days, Ladontay’s doctor was able to fill the prescription for his new, flexible glasses. With his new glasses, Ladontay’s reading and schoolwork will improve and he will be able to participate more fully in sports.

In her fight to obtain the medical care that Ladontay needed, Judy also spoke for many other parents struggling to obtain care for their children. She said, “When I contacted the Tennessee Justice Center, you steered me in the right direction. Your help was a lifesaver. I am so thankful.” She continued, “Without the Tennessee Justice Center, I would have just taken “no” for an answer. Now, I know my rights.”

Health Care Story of the Week - 2/4/10

Eleven-year-old Chance enjoys being outdoors. He loves to play basketball and go swimming. Chance was born with hearing and vision impairments as well as serious psychological and neurological problems.

After a recent hospitalization, Chance was discharged but desperately needed follow-up care. Chance’s doctors had ordered residential treatment for him. This intensive level of care and therapy is Chance’s opportunity to develop to his fullest potential. To avoid social isolation due to his deafness, Chance’s doctors recommended placement at a facility where both the staff and the residents could speak to him in sign language. Integrating Chance in a social setting during his treatment increases the likelihood that Chance’s therapy will succeed, and that upon discharge he will be able to function well at home and in school. Originally, TennCare indicated that it would not cover this specialized treatment for Chance.

Chance’s behavior was out of control due to his disorders and he posed a serious risk to himself, his family, and his peers. He could not return to school. He could not be around other people. In order to keep their son, their family and their neighbors safe, his mother, Kim, stayed with Chance at a State Park. Knowing she could not remain awake around-the-clock to watch over Chance, Kim called TJC for help.

With the help of the Tennessee Justice Center, Chance received the care his doctors recommended. TJC’s advocacy ensured that TennCare will cover the treatment for Chance at a facility that works specifically with deaf children who have multiple special health needs.

Chance’s mother wrote to TJC on behalf of the family: “Thank you so much from all of us, especially Chance. We finally have so much more hope for him.”