The Top Ten Health Policy Stories of 2010, Part 1

2010 was the most significant year in health policy since the 1960s.  It dominated the policy agenda for the first few months of the year, and it stayed in the news throughout the election season.  As the year drew to a close, conflicting lower court decisions about the constitutionality of the individual mandate foreshadowed a continued policy debate into the foreseeable future. 

What makes a health policy story big in a time of change?  It’s not just the attention it commands in the media.  It’s the impact it has on our lives. 

This week and next, I’ll countdown ten.   Using the impact criterion, there were actually some that weren’t part of health reform!   

Here are my choices for numbers ten through six.

10. The Election of Senator Scott Brown.  It is hard to remember that as we entered 2010, the Democrats seemed to be putting the finishing touches on a bill that could pick up 60 votes in the Senate.  Lincoln, Lieberman, and Nelson were among the ones to whom everyone was paying attention.  Then, Scott Brown was elected in Massachusetts, and everything changed.  The Democrats lost control of the issue and public opinion.  That one special election almost derailed the entire effort and ultimately changed the look of the final legislation.

9.  The Change in Tax Treatment of Dependent Health Insurance.  Until the IRS changed the rule in March, when you kept your child on your health insurance up to age 26, you paid taxes on the benefit.  Had this not been changed, then the health reform provision allowing parents to keep adult children on their insurance would have been a mixed blessing at best.  Many might have refused or been unable to do so when they factored what could have been hundreds of dollars of increased taxes.

8. The Death of the Public Option.  Even though it had majority support in both chambers, Congress put the public option to rest early in the year when leaders realized that they could not muster the 60 votes necessary to overcome a Senate filibuster against it.  Once it was gone, public sentiment tilted slightly against health reform.  Reform-minded Democrats were upset with their Congressional leadership, and a portion of the Democratic base disappeared along with it.  Proponents and opponents of reform seemed to agree on one thing – if a public option had been offered to people, many would have chosen it because it likely would have been less expensive than some or all of the private alternatives. 

7.  The Rebirth of the Public Option.   No one called it this, but when the final health reform bill included an expansion of Medicaid reaching 17 million new people in 2014, including nearly every family with income under $30,000, the public option was alive again – at least for people at lower income levels.  With Medicare also a public program, the only people left in the private insurance market were those under age 65 earning $30,000 and up.  And the reform law provided for subsidies for most of them.  We may not yet have the single payer system that progressives wanted, but we might still be headed in that direction. 

Public options are not going anywhere soon.  Mike Huckabee, who will likely be a significant early player in the Presidential campaign, favors repeal of the new law.  This fall he argued for a further expansion of the Medicaid program as an alternative to the mandate that insurers cover people with pre-existing conditions.  It’s pretty clear.  In the light of the day and out of the heat of the moment, so long as public options are called something else, they often generate support across the ideological spectrum.

6.  Mental Health Parity.  Mental health parity this year was an under-the-radar policy story with sweeping consequences. New mental health parity provisions, enacted in 2008, finally became law in 2010.  For the first time ever, mental illness must be given the same treatment in insurance as other chronic conditions. 

It became harder than ever for public officials not to do this as increasing numbers of people with mental illness advocated for fairness, and as other chronic conditions, like diabetes and hypertension, became more common and more costly.  Parity is a big deal, especially to the millions of people with serious mental illness, but when it happened at the beginning of the year it got little attention in media consumed by the fiery health reform debate.

Ironically, the mental health parity law also attracted little news attention when it was passed in late 2008.  Why was this?  It was tacked onto the first major financial bailout bill signed into law by former President Bush!

Next Wednesday, I’ll give you my top five health policy stories of the year. 

Mike Huckabee's Public Option

If you watched HBO’s Real Time with Bill Maher on November 12th, you heard Mike Huckabee propose a public option as part of a health reform fix.  With “repeal, revise, and replace” stories in the news every day, shouldn’t this be worth at least one national headline? 

Governor Huckabee didn’t just flirt with the public option; he married it to his opposition to requiring insurers to cover people with pre-existing conditions.    

Defending his position, Huckabee argued “when you buy insurance you’re buying something in the private sector.  Now maybe there’s a place to say if you’re really, really sick and you can’t access a traditional marketplace then should we have some form of safety net?  Yeah. I’ve said that; I did that when I was Governor.”  

He called for “a partnership between government and the private sector” to insure people with pre-existing conditions. So what did Mr. Huckabee propose? 

He cited the Arkansas TEFRA program he started for families of children with serious chronic conditions as the model safety net program he would favor for people with serious illnesses.  In that program, Arkansas allowed families earning between $25,000 and $200,000 per year the option of buying into the state’s Medicaid program by paying annual premiums of between $504 and $5,500.  After the family paid the premium, the state and federal government paid the cost of the care.

If you expand the Medicaid program and use means testing to include people with serious illnesses, this is about as public an option as you can get – even if you pass it off as just a “safety net.”

How Many People Have Serious Chronic Conditions?

How many people could this public option affect?  The answer is surprising – well over 100 million if he covered just those with serious medical conditions, and up to half of all Americans if he offered the option to all those with chronic conditions. 

I’m one of them.  Like 55 million other adults, I suffer from chronic back pain.  In the past twenty years, I’ve been to doctors, hospitals, and physical therapists for it, and taken prescriptions and over-the-counter pain medications.   

Back pain is inconvenient, but hardly life-threatening.  It could be different for me.  I could be one of the almost 75 million Americans with hypertension.  They may not have outward symptoms like I do.  But if they don’t manage their condition, it could lead to serious health consequences for them. 

Or things could be worse.  My condition could be serious and costly.  I could be one of the 100 million or so Americans with at least one serious and even life-threatening condition who need ongoing treatment.

I could be one of the 34 million with asthma, the 30 million with heart disease, the 24 million with diabetes, the 14 million with serious mental illness, or the 12 million with cancer. 

Death Sentences?

When insurance companies refuse to insure these people because of their conditions, they give some of them a death sentence. 

This isn’t an exaggeration.  Without insurance, many people can’t even afford the tests for their chronic conditions, much less the treatment. 

Consider this:  A member of my family had a bout with cancer a few years ago, and the treatment cost well over $100,000.  She now has annual diagnostic tests to make sure the cancer hasn’t returned.  The price of this year’s tests was exactly $3,171.20.

If she were uninsured, she would have had to find the money for the treatment and the tests.  If she couldn’t afford the treatment, why do the tests?  If she couldn’t even afford the tests, then she would be gambling with her life.   

Why Sick People Need Insurance the Most

Insurance does two things for us when we’re sick, and this is why the sickest people need insurance.

It doesn’t just pay most of the cost; it also negotiates down the price for tests and treatment.  My family member’s insurer negotiated the price of this year’s tests down from over $3,100 to just over $1,400.

Taking on both roles costs insurers money.  That’s why requiring insurers to cover people with chronic conditions draws opposition from Mr. Huckabee.  He prefers a publicly-funded safety net.

This past summer, insurance commissioners in Florida, California, Michigan, Virginia, and Nebraska all said that they did not have the authority to enforce the consumer protection provisions of the health reform law. 

If they don’t enforce these protections, or if Mr. Huckabee were to convince Congress to repeal some of them, then what will people with pre-existing conditions do?  Their only alternative would be something like Mr. Huckabee’s public option.  As a credible conservative voice and leading Republican Presidential candidate, will he be willing to sell this public option to a broad national audience, or was this just a one-night stand for him?