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Today's Health Insurance Topic:: Government's Role In Health Insurance

JANUARY 27, 2009 -- Congress and the incoming Obama administration are contemplating profound shifts in the government's role in health insurance to try to alleviate a significant ripple effect of the damaged economy: Americans losing health coverage as they lose jobs.

As part of a sprawling $825 billion strategy to heal the economy that House Democrats laid out this week, lawmakers and transition officials envision a two-prong approach to help unemployed people retrieve health benefits. One would reshape a basic entitlement program, allowing states temporarily to sign up jobless residents for Medicaid, with the federal government for the first time paying the entire cost. The other proposal would provide unprecedented federal subsidies to help people afford coverage under COBRA, a law that allows some laid-off workers to buy health benefits that they used to get through their jobs.

The twin ideas, preliminarily estimated to cost $39 billion through the end of next year, would represent sharp departures in two long-standing programs and already are sparking debate along the ideological continuum on Capitol Hill and beyond. In Congress, several key Democratic House members and senators have endorsed the broad contours, while a few Republicans, including Senate Minority Leader Mitch McConnell (R-Ky.) have signaled that they are wary. Debate, however, will not solidify until lawmakers learn more precisely how much the proposals would cost and how many people they might help.

Among outside health policy specialists, conservatives are critical of expanding an entitlement and are predicting that states would have a hard time shutting the spigot of help once the federal money stopped. Liberals are predicting that, even with the large federal investment, coverage could remain unaffordable for too many people.

The ideas' boldness reflects a precipitous rise in the uninsured. Recent estimates suggest that worsening unemployment, which reached 7.2 percent last month, translates into a loss of health coverage for an additional 2.6 million people. That increase, on top of the estimated 45 million uninsured, is exacerbating a persistent problem in the U.S. health-care system: too many people who lack access to proper care.

Politically, including insurance help for the unemployed in a fast-acting economic stimulus package is part of a strategy by congressional Democrats and President-elect Barack Obama to place attention on health care right away. It is in sync with a decision to pursue immediately an expansion of health insurance for poor and working-class children, long resisted by President Bush, which the House adopted on Wednesday and a Senate panel approved the next day.

Taken together, the insurance for children and laid-off workers signifies an effort by Democrats to create momentum for the more difficult work of broad health reforms that they and the Obama administration plan to undertake soon. In recent weeks, lawmakers have collaborated with the incoming administration to devise remedies for the jobless uninsured and to decide how much money to allot. A transition aide said: "Obama supports the protection of health insurance through COBRA and Medicaid in a time-limited way."

House Democrats say publicly that they would like to devote $30 billion over two years to subsidize COBRA and $8.6 billion to expand Medicaid. Privately, legislative sources said those figures are premature, because lawmakers are awaiting budget analyses of how much the proposals would cost -- and how many unemployed Americans would be likely to grasp the help.

The Medicaid proposal would give assistance through 2010 and would break with significant features of the program created as part of the Great Society of the 1960s. Medicaid always has been a shared financial responsibility of the U.S. government and the states. But under the proposal, federal money would pay for all benefits and administrative costs for unemployed people who joined. In addition, the expansion would be the largest step ever taken beyond Medicaid's original purpose of insuring people who are poor or disabled. There is precedent in recent years for opening Medicaid in times of crisis -- for some New York residents after 9/11 and for people who fled communities ravaged by Hurricane Katrina -- but not on the scale envisioned now.

Specifically, House sources said, the government would give states the option of allowing unemployed people to join Medicaid but would not require states to do so. States could choose whether to include three groups of uninsured residents: people who are receiving or have used up unemployment benefits, no matter how much money they have; unemployed people who qualify for food stamps, which in many states are available to residents somewhat less poor than Medicaid requires; and laid-off people with incomes as much as twice the poverty level who would not otherwise qualify for Medicaid. The last group is aimed, in part, at adults without children who are not allowed into Medicaid in most states.

House leaders said the COBRA proposal would subsidize for one year 65 percent of the price of premiums for private insurance that laid-off workers bought. According to legislative sources, that level of help could ultimately change, depending on feedback from congressional budget analysts.

For the past two decades, COBRA has guaranteed that certain laid-off workers may, if they pay for it, continue the insurance they used to get through work -- usually for 18 months. But the government has never helped them afford it, and coverage is expensive. Under COBRA, employers may charge former workers 100 percent of the insurance cost -- an average of about $12,000 a year for a family -- plus a small surcharge.

Research has shown that a small fraction of people eligible for COBRA buy it. A study released last week by Families USA, a liberal consumer health lobby, said COBRA is "an economic impossibility" for most people, because its typical costs would use up nearly 84 percent of the average unemployment benefits.

Stan Dorn, a health policy researcher at the Urban Institute, predicted that it would still be unaffordable for many if the government offered to pay 65 percent of the price. He has studied the only similar idea in place today, a provision in a 2002 trade bill that offers tax credits worth 65 percent of insurance premiums to a small group of dislocated workers. Just 12 to 15 percent of them have taken the offer, largely because the remaining 35 percent of the premium is still beyond their means. If the COBRA subsidy were for the same amount, Dorn predicted, "there is a very good chance the program will be a major failure."

However, conservatives worry that the temporary help for people to join Medicaid would be a back door to a permanent expansion of the entitlement. Nina Owcharenko, an analyst at the Heritage Foundation's Center for Health Policy Studies, predicted that, even if the extra federal money were for two years, states would face pressure to maintain the benefit. Otherwise, she said, "It's seen as kicking people off the program." She suggested that the government, instead, offer states help in finding unemployed people private coverage, which might be less generous and less expensive.

One House aide said how much help the government can afford -- and how many people might take part -- will remain unclear until the budget analyses are finished. In the meantime, he said, "this is far from a perfect solution, but it is going to help some people."

Follow these tips to get the best insurance coverage for your dollar.

In 2008, the financial services sector alone shed 148,000 jobs, according to the latest figures released Friday by the Bureau of Labor Statistics. For these laid-off workers, losing their salaries had to hurt; losing their employer-sponsored health care benefits could hurt more. Whether it's paying the full cost of the premium or buying insurance independently, trying to find the right health coverage after being thrust into unemployment can be an overwhelming challenge.

There's jargon to decipher, deadlines to consider and the sticker shock of purchasing health care without an employer contribution. The costs vary greatly, with a study by eHealth Insurance finding that, when purchasing a policy directly from a provider, premiums average $158 for individuals and $366 per month for families, but with sky-high deductibles--$1,972 and $2,610, respectively. Never mind the costs, the complexity of insuring one's self can lead to poor decision making.

"If you find yourself suddenly without work," says Ellen Laden, a spokeswoman for United Healthcare's individual business, "often it's most tempting to go without health insurance. But it's the time you can least afford to have an accident or injury." Laden and other insurance experts stress that the newly uninsured have several options, but the hard part is figuring out which solution is best for you.

Extending Coverage

Frank McCauley, head of Aetna's (nyse: AET - news - people ) consumer business segment, says that extending coverage for the right length of time and at the right price requires asking yourself three basic questions.

First, how long do you expect to go without insurance? A six-month coverage gap should be handled much differently than a 36-month gap. Second, what extent of coverage do you require? A 45 year old in perfect health, for example, will have different needs than a 60-year-old diabetic. Lastly, how much do you want to spend on a premium? A low-cost premium might be attractive in the short term, but this is often paired with expensive deductibles. If you plan to use your insurance, it's wise to pay a premium relative to the expected out-of-pocket expenses.

The Consolidated Omnibus Budget Reconciliation Act (COBRA), say both Laden and McCauley, can be an ideal solution for a worker who wants to keep his or her coverage for up to 36 months. Under COBRA, the former employee still participates in the company plan if he or she pays the full premium.

There are a few hitches, though. This alternative is only available to former employees of firms with more than 20 workers. And if the employer stops offering health insurance or if the company is dissolved in a Chapter 7 bankruptcy, COBRA may be no longer applicable. Finally, it can cost up to 102% of the plan's cost--the extra 2% is for administrative expenses.

"Employees are not used to seeing the total cost," says Laden. "You can pay three or four times more than what you're currently paying," because an employer often subsidizes 75% to 80% of the plan's cost. Coverage for an average family in 2008 was $12,680 and $4,704 for an individual, according to the Kaiser Family Foundation, a nonprofit health policy organization.

Getting the Best Deal

When investing that much, it's important to shop around. The Department of Labor maintains a comprehensive Web site on COBRA, which includes information on deadlines and life-long eligibility for coverage when COBRA expires.

McCauley also suggests that the uninsured explore obtaining coverage through a spouse. Depending on the carrier and company policy, the newly uninsured may qualify for spousal coverage. If unemployment does not count as a so-called "qualifying event," you may need short-term insurance until the once-a-year open enrollment phase.

Another option, says McCauley, is purchasing insurance through professional or membership organizations. AARP, for example, has partnered with both Aetna and United Healthcare to offer insurance to members. While AARP members buy directly from the individual market, in some cases professional organizations allow consumers to take advantage of discounted group rates.

Finally, carriers offer many short- and long-term options. United Healthcare's one- to six-month plan can be extended an additional six months if necessary. It does not cover preventive care, like an annual physical, but it is insurance against unexpected ailments and injuries.

The deductibles run between $250 and $500, but the carrier refunds unused premiums. Providers that don't offer short-term coverage--like Aetna--sometimes allow plans to be canceled without penalty and often offer a wide range of long-term options, including high-deductible and PPO policies. To compare various policies, McCauley recommends ehealthinsurance.com, a Web site where consumers can evaluate different quotes based on their age, location and health status.

"There are options available," says Laden, "that will cover the needs of most everyone."

Doom And Gloom Ahead? If you still have health insurance but are worried about potential layoffs, it is crucial to become proactive about your health.

The good news, according to analysts at the consulting firms Mercer and Watson Wyatt, is that most large companies are not planning to eliminate benefits in 2009. However, many have asked employees to contribute more toward their rising premiums. A Watson Wyatt survey of 117 U.S.-based companies in December showed that 20% of them had raised employee contributions for 2009.

Ted Nussbaum, director of health care consulting in North America for Watson Wyatt, says employees should take advantage of free health-improvement programs. These include health risk evaluations, routine screenings and weight management programs, and they often come with financial incentives used to encourage employees to maintain good health.

For example, the building materials company LaFarge, which is a Mercer client, has invested $6.5 million in preventive initiatives. Employees who get an annual wellness exam and routine cancer screenings, for example, receive a $75 gift card. The incentives have boosted the number of employees who participate in such programs from 700 in 2007 to 4,500 in 2008.

Philia Swam, director of health and group benefits at LaFarge, says the program has been so successful that it even led to early detection of colon cancer in a 50-year-old male employee. It's an encouraging story, particularly for those who still have benefits. The lesson? Get healthy while the resources are still affordably at your disposal.

Editorial: About Health Insurance -- Even before taking the oath of office, President-elect Barack Obama has gotten traction on his agenda to expand health insurance to all Americans - starting with children.

The U.S. House voted with impressive bipartisan backing to boost spending for the State Children's Health Insurance Program (SCHIP). The $32.3 billion, 41/2-year program will be covered by tobacco taxes, including a 61-cent hike on cigarette packs, to $1.

With 40 Republicans joining Democrats in the majority, lawmakers reauthorized the child health program until 2013. Beyond the seven million children from low-income families already in the program, an additional 4.1 million children under 18 who are uninsured could sign up. In a key reform, more legal immigrants' children would be covered.

In Pennsylvania, New Jersey and Delaware, more than 250,000 children would be able to receive health care under the program. No wonder U.S. Rep. Allyson Y. Schwartz (D., Pa.) - who pioneered children's insurance programs while a legislator in Harrisburg - said on the House floor that "today is a good day for American families." Now it's up to the Senate to follow suit and approve a companion bill to the House measure. That seems entirely likely, inasmuch as Congress twice in 2007 voted to expand SCHIP - only to have both attempts vetoed by President Bush, who objected to the increased cost.

Landing this bill on Obama's desk soon would be an important early win for the administration, and also would bode well for more comprehensive health-care reform to follow. Pennsylvania and New Jersey are poised to make the most of an expansion of the children's insurance program. Both Govs. Rendell and Corzine have worked hard to get more kids insurance, even while Bush policies worked against them.

Rendell's Cover All Kids plan last year ran up against a Bush directive that limited states in providing children's insurance. As Corzine noted Thursday, New Jersey's charity-care costs grew in caring for the state's sizable number of legal immigrant children who, until now, had to live in the country five years before enrolling in SCHIP. By taxing tobacco for the expansion, Congress has answered critics on the cost - for now. Additional tax hikes may be needed if the program's cost increases. With unemployment rising and the economic turmoil threatening millions of workers' health insurance, though, the boost in SCHIP should be viewed in the larger context of the nation's economic rescue and recovery efforts.

In other words, it's a good investment in stabilizing families and helping to assure that America's neediest kids have a healthy future

 

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