Consumer protections get lost in health-care debate

WASHINGTON -- It's one issue in the health-care debate that nearly everyone, even the insurance lobby, seems to agree on: Better consumer protections are needed to end the problem of not being able to get covered for a treatable illness.

Yet such practical considerations are being overlooked in a debate that's become an argument about the government's reach and role in medical matters.

Experts say the bills before Congress include significant consumer protections that would end denial or cancellation of coverage for medical reasons, from high cholesterol to cancer.

Insurers no longer could base premiums on a person's medical history, although they still could charge more to 50-year-olds than to people in their 20s.

People buying their own policies, and those working for small businesses, would gain many of the advantages employees of Fortune 500 companies now have. That would eliminate "job lock," the fear of leaving employment that provides medical benefits.

"It would bring insurance and insurability standards into line with medical practice and with the way people live their lives," said Dallas Salisbury, president of the not-for-profit Employee Benefit Research Institute.

If President Obama's effort to remake the health-care system implodes, chances are slim that such protections could be enacted on their own. What consumer groups call discrimination by insurance companies, the industry sees as self-defense against people who put off getting coverage until they're seriously ill.

Major insurers will accept a rollback of the industry's restrictive practices only if they're guaranteed that all Americans would be covered -- a central goal of Obama's approach and a potential financial boon to the industry.

The consumer protections are part of what Republican Sen. Mike Enzi of Wyoming calls the 80 percent of health-care fixes that there's consensus for. Enzi is one of six members of the Senate Finance Committee who are trying work out a bipartisan solution -- with no guarantee of success.

Obama may have made a critical error by not stressing the consumer aspects of the legislation, and his advisers seem to have realized it as they belatedly retooled the White House pitch in recent days.

If a bill does pass, the biggest winners are likely to be self-employed people and small-business owners and employees, who now have the most trouble getting and keeping coverage. Those working for big companies would only benefit indirectly; they'd find it easier to keep their coverage if they get laid off or leave to launch a new career.

Insurance companies could come out ahead, too.

"They'll get a big new market with millions and millions of new customers," said Gary Claxton, a health policy expert with the Kaiser Family Foundation. "Their average profit per person may not be as high, but they still should be able to earn a profit by insuring more people."

One major catch is that the consumer protections would not be available immediately. They are timed to take effect alongside government subsidies to help people buy coverage. In the House Democratic legislation, the coverage expansion would come in 2013 -- after the next presidential elections. Part of the reason for the delay is to make the costs of the bill appear more manageable.

"It's a long time to wait," said John Rother, policy and strategy chief for AARP. "This is complicated stuff, but I would have personally liked to see it done in two years."

The House legislation, the Senate health committee bill and the evolving Senate Finance Committee package differ on some important specifics, but follow the same general approach.

All would set up an insurance marketplace. This exchange would be open to individuals and small businesses, and maybe big companies later on. Government subsidies would be available for low-to-middle income households. People buying health insurance through the exchange would be part of a large pool that spreads risks, giving participants leverage similar to what government employees -- including lawmakers -- now have.

Health plans offered through the exchange would have to meet basic standards, so it would be easier for consumers to understand what their insurance covers. To protect against catastrophic illness, there would be annual limits on out-of-pocket costs for co-payments and deductibles. Year-to-year increases in premiums would be more predictable for small companies.

Insurers could not charge more to people in poor health or to women, as they do now. But they still could charge higher premiums due to family size, geographic location and age.

The House and the Senate health committee bills would limit age-related premiums so that a 64-year-old pays no more than twice as much an 18-year-old. But Senate Finance Committee negotiators are considering allowing as much as a 5-to-1 difference, a big savings for the young but a significantly higher cost for older people who are more likely to have health problems.

The federal consumer protections would set a basic standard for the whole country, changing a situation in which state-level safeguards vary widely.

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On the Net:

Employee Benefit Research Institute: http://www.ebri.org/

AARP: http://www.aarp.org/

Kaiser Family Foundation: http://www.kff.org/

Senate Finance Committee: http://finance.senate.gov/

Senate Health, Education, Labor and Pensions Committee: http://help.senate.gov/

House Energy and Commerce Committee: http://energycommerce.house.gov/

House Ways and Means Committee: http://waysandmeans.house.gov/

House Education and Labor Committee: http://edlabor.house.gov/