High Voltage Shareware/high1.zip/high1/DIR23/HREPORT.ZIP/CHAPTER4.TXT

Text File | 1993-10-26 | 24KB | 549 lines

Chapter 4 -- SECURITY



     "Six months ago, my sister-in-law, Pam, had a disabling
stroke.  Pam is only 39 years old, and she's a severe diabetic.
Six months have passed, her short-term memory has deteriorated,
her vision is leaving, and it looks as if my brother will either
have to hire someone to come into their home full time to care
for her, or put her in a nursing home, which his medical plan
does not cover.

My brother's attorney has advised him to divorce Pam so that her
medical bills don't pull him into financial ruin.  My brother has
two young sons that he's caring for and in order to continue to
provide for them, he is giving this consideration...

A man who loves his wife must divorce her so that her misfortune
(in sickness and in health) does not leave him with the inability
to raise their family."

A.P.
Toledo, Ohio
________________________

     Americans buy health insurance to provide security for
themselves and their families.  Security, in its full sense, is
what health care reform must give us all. We must be secure that
no American will face exclusion from coverage because of illness,
occupation or age.  We must be secure that health benefits will
be comprehensive enough to keep us healthy and cover our health
care needs throughout life.

Comprehensive Benefits

     Under the Health Security Act, all American citizens
and legal residents will be guaranteed a comprehensive package of
health benefits that can never be taken away.  They will receive
a Health Security card entitling them to enroll in a health plan.

     Everyone will have a choice of at least three -- and, in
most communities, many more -- health plans. And no matter which
plan people choose, they will receive the comprehensive benefits
package.

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Sidebar - Pg 34-35

Covered Benefits



     Benefits covered under the nationally guaranteed
comprehensive package carry no lifetime limits.  The package
covers the following health services when they are medically
necessary or appropriate:

*  Hospital services, including bed and board, routine care,
   therapeutics, laboratory and diagnostic and radiology services
   and professional services.
*  Emergency services.
*  Services of health professionals delivered in professional
   offices, clinics and other sites.
*  Clinical preventive services.
*  Mental health and substance-abuse services (for details, see
   box on mental health and substance abuse).
*  Family planning services.
*  Pregnancy-related services.
*  Hospice care during the last six months of life.
*  Home health care, including skilled nursing care, physical,
   occupational and speech therapy, prescribed social services and
   home-infusion therapy after an acute illness to prevent
   institutional care.
*  Extended-care services, including inpatient care in a skilled
   nursing home or rehabilitation center following an acute illness
   for up to 100 days each year.
*  Ambulance services.
*  Outpatient laboratory and diagnostic services.
*  Outpatient prescription drugs and biologicals, including
   insulin.
*  Outpatient rehabilitation services including physical therapy
   and speech pathology to restore function or minimize limitations
   as a result of illness or injury.
*  Durable medical equipment, prosthetic and orthotic devices.
*  Routine ear and eye examinations every two years.
*  Eyeglasses for children under age 18.
*  Dental care for children under age 18.



Planned Expansion of Benefits



     Beginning in the year 2001, the nationally guaranteed
benefits package will expand to include the following:

*  Preventive Dental care for adults.
*  Orthodontia if necessary to prevent reconstructive surgery for
   children.
*  Expanded coverage for mental health and substance abuse
   treatment.

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     The coverage provided by the comprehensive benefits package
equals that provided by America's major employers, such as
Fortune 500 companies.  It covers a full array of clinical
services, from doctors' offices, to clinics, to hospitals, to
rehabilitation centers, to laboratories, hospices, home-health
agencies and other professional offices.

     The comprehensive benefits package provides far more
coverage for clinical preventive services than traditional
insurance.  It waives the usual co-payments and deductibles for a
wide range of preventive services that are vital to keeping
people healthy.  Preventive services covered without co-payments
include prenatal, well-baby and well-child checkups, physicals
for adults, immunizations and regular screening tests such as
mammograms and Pap smears.

     The Health Security Act particularly expands preventive
services for certain low-income women and children.  By fully
funding the Special Supplemental Food Program for Women, Infants
and Children (WIC), more families will be able to receive
nutrition counseling and get nutritious food -- part of the
overall strategy for keeping people healthy rather than waiting
until they get sick.

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Sidebar - Pg 36

Preventive services


     The Health Security Act offers comprehensive coverage for a
specific set of preventive screenings, laboratory tests and
periodic checkups.  Included in the benefit package, at no cost
to the consumer, is coverage for preventive care such as
immunizations and specific screening tests.

     Some preventive services will be targeted to groups that
have a high risk for certain diseases, such as men considered
especially vulnerable to cardiac problems and women with a close
family history of breast cancer.  Children will receive a full
range of prevention services, including immunizations, well-baby
checkups and developmental screenings at no extra charge.


***************************************************************

________________________


     "We believe reform will enhance both medical security for
the nation's 65 million children and peace of mind for their
parents.  We are especially impressed by the commitment of
yourself and the First Lady to ensuring all children have access
to appropriate health care, because it is such an important
investment in the nation's future"

Lawrence A. McAndrews, President and CEO
National Association of Children's Hospitals
and related institutions.
September 21, 1993
____________________


     The benefit package also expands traditional coverage of
mental health and substance abuse treatment.  Insurance companies
often tightly limit their coverage of mental health; they adopt
that policy partly because they depend on the public mental
health system -- and the taxpayers who pick up the bills -- to
serve millions of people who lack coverage for even basic
treatment, or who suffer from chronic or serious illness. The
Health Security Act eliminates the lifetime limits on mental
illness that can devestate family savings; and it  provides
coverage for regular clinical visits, and offers more flexible
care.

     For millions of Americans, the comprehensive benefits
package will provide a significant expansion of coverage.  Those
whose current benefits are more generous -- a much smaller number
-- will have every right to continue receiving richer benefits.
Nothing in the Health Security Act prevents employers from
providing more extensive benefits, with no strings attached.

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Sidebar - Pg 38

Mental health and substance abuse



     The Health Security Act offers Americans guaranteed coverage
for mental illness and substance abuse, ending the agony that
families confront when a serious mental illness occurs.

     The benefit package gradually expands coverage for mental
illness and substance abuse, both for inpatient and outpatient
therapy.  Out-patient services will include diagnostic office
visits for medical management, substance abuse counseling, and
relapse prevention.  The benefit package also provides coverage
for a wide range of new approaches, such as intensive care
delivered outside the hospital.

     The Health Security Act eliminates lifetime limits on mental
health and substance abuse treatments.  Initially it contains
limits on the number of days of inpatient and outpatient
treatment, but it commits to removing those limits by the year
2001.

Types of services covered:

*  Inpatient care
*  Alternative treatment programs which provide intensive care
   outside hospitals
*  Outpatient therapy with requirements for patients to share
   part of the cost.
*  Brief office visits and medical management for patients who
   take medication.


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     Not everything is covered in the benefits package. It would
just be too expensive. Examples of services that are not covered
include:

     *  Services that are not medically necessary or
        appropriate
     *  A private room in a hospital
     *  Adult eyeglasses and contact lenses
     *  Hearing aids
     *  Cosmetic surgery

     Individuals will be free to purchase supplementary
insurance, although the comprehensive benefits package leaves
little need for additional coverage.  Employers are also free to
offer additional benefits or absorb co-payments and deductibles.

     However people choose to receive health care, the Health
Security Act guarantees all Americans something no amount of
money can buy in today's insurance market:  the knowledge that
they will always have comprehensive health benefits that can
never be taken away -- no matter what happens in their lives or
their jobs.  If they lose a job or change employers, coverage
will continue without interruption.  If they move, get married,
separate from a spouse, experience a catastrophic illness or
confront any other crisis, their health coverage will continue
uninterrupted.

Insurance Reform

     The Health Security Act outlaws discriminatory insurance
practices that prevent millions from obtaining health coverage
today.  It will return the concept of health insurance to its
roots: offering protection to everyone whether they're healthy or
sick, young or old. It will put an end to the practice of
underwriting -- searching for only the healthiest people to
insure.

     Under the Health Security Act, health plans will be required
to:

*  Enroll everyone who applies, whether they're healthy or sick,
   young or old;
*  Charge everyone the same price for the comprehensive benefits
   -- no more charging higher rates to sick people, older people, or
   people with pre-existing conditions;
*  Provide coverage without resorting to "lifetime limits" that
   cut off coverage when people need it most; and
*  Limit deductibles in fee-for-service plans to $200 for an
   individual and $400 for a family.

     By establishing a uniform, comprehensive benefits package,
the Health Security Act no longer makes it advantageous for
insurance companies to shape benefits and policies that attract
the healthy and avoid the sick.  Health alliances, in turn, will
help organize the private market so that consumers -- for the
first time -- can compare plans and providers and make informed
choices.  Their mission will be to promote competition among
health plans based on quality and price -- not on who can screen
out sick patients.

Limits on What Consumers and Businesses Pay

     The Health Security Act also takes several important steps
to protect families and businesses from rising health costs and
financial ruin.  To provide secure financial protection against
the most devastating illnesses and injuries, it prohibits
so-called "lifetime limits" and restrictions on the amount of
medically necessary or appropriate care.  The limits, which are
included in six out of every ten insurance policies today, can
mean bankruptcy for families in which catastrophic illness
strikes.  The Act also sets maximum annual out-of-pocket limits;
even those who select the most expensive plans can spend no more
than $1,500 a year for an individual, or $3,000 for a family.
Insurance picks up the full cost of any medical care that exceeds
those limits.

     The Health Security Act also limits deductibles -- the
amount people pay each year before insurance kicks in, which can
run into the thousands today -- to $200 for individual's and $400
for families who choose traditional fee-for-service plans.

     Employers will pay a maximum of 7.9 percent of their payroll
for health care.  Small businesses -- those with fewer than 75
employees -- will receive discounts of between 30 and 80 percent,
compared to what the average large business pays.  And the
self-employed will be able to deduct from their taxes 100 percent
of their health care, up from today's 25 percent.


PROTECTING OLDER AMERICANS

     The Health Security Act preserves and protects the Medicare
program, providing older Americans with the health security they
deserve.  People covered by Medicare will see little difference
in how, where or from whom they receive their health care, but
they will receive new prescription drug benefits.

     Americans eligible for Medicare will automatically receive
the new prescription drug benefit -- which will cover drugs and
biological products, including insulin, approved by the Food and
Drug Administration -- when they enroll in the Part B benefit,
which covers physician and other outpatient services.  Under the
drug benefit, there will be a $250 annual deductible for each
person.  Individuals on Medicare will also pay 20 percent of the
cost of each prescription up to a maximum of  $1,000 over the
course of a year.

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Sidebar - Pg 42


Early Retirees


     When Americans over age 55 find that health problems or
other events require them to stop working, they often confront
the worst possibilities in the current health insurance market:
because of age, or medical conditions, individual coverage is
difficult to obtain or very expensive. Under health care reform,
American workers who retire between the ages of 55 and 64 will
never have to worry about losing their health coverage.

     Under the Health Security Act, individuals over age 55 who
retire before they are eligible for Medicare will pay for their
coverage like other people who do not work and will be eligible
for discounts based on income.

     When reform is fully implemented, at the end of this decade,
early retirees will become eligible for greater discounts
requiring them to pay only the portion of their insurance premium
that they paid as employees, unless they have an annual income
higher than $100,000 for an individual, or $125,000 for a couple.

     To be eligible for this greater discount, early retirees
will have to have worked for ten years, the same standard used
for eligibility under the Social Security Act.

     The coverage for early retirees in the Health Security Act
will provide a major financial benefit to employers who
traditionally cover the cost of retirees' health premiums.

     Employers who wish to provide coverage for any or all of the
retired employee's share of the premium or for cost sharing
required by health plans will continue to do so, as they do
today.

     When they reach age 65, retired workers have the choice of
staying in their health plan or enrolling in Medicare, just as
they do today.


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     Part B premiums will increase about $11 a month to cover 25
percent of the cost of this new benefit.  But for seniors who
have Medigap policies, which cover services not provided by
Medicare, premiums for those policies should decline since they
will no longer cover prescription drugs.

     As Americans enrolled in health plans through alliances turn
sixty-five, they can choose between remaining in their health
plan or entering the Medicare system.

     Older Americans will also see their long-term care options
expand and improve under health care reform.  The Health Security
Act creates a new home and community-based care program and
expands the range of choices for disabled individuals who require
long-term care.

     Among other things, the Health Security Act will:

*  Expand home and community-based services;
*  Improve Medicaid coverage for people in nursing homes;
*  Improve the quality and reliability of private long-term care
   insurance and provide tax incentives to encourage people to buy
   it; and
*  Provide tax incentives to help people with disabilities work.


ACCESS TO CARE IN RURAL AND URBAN AREAS

     The challenges of guaranteeing health security in rural and
inner-city communities are essentially similar:  both include
unusually high numbers of people without health insurance, making
it difficult to attract doctors.  Scarce economic resources
create barriers to organizing effective networks of care.

     Greater incidence of poverty aggravates health problems.
Many people in these areas require special services -- rides to
the doctor, babysitting and translators, just to get access  to
health care services.

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Sidebar - Pg 44

Long-Term Care

     Beginning in 1996, a new home and community-based care
program will enable older Americans with severe disabilities to
remain in their own homes or with their loved ones, yet still
receive the care and assistance they need.

     Medicaid nursing home coverage will be enhanced, allowing
nursing home residents to keep $70 per month for living expenses.
States will have the option to provide even greater financial
protection by allowing individuals to retain up to $12,000 in
assets, instead of today's $2,000.

     The Health Security Act also provides tax incentives to
encourage people to buy private long-term care insurance that
meets new standards, and tax incentives to help individuals with
disabilities to work.


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     Although urban and rural areas have some of the same
problems, the circumstances that cause them are often very
different.  In rural areas, geography is the main obstacle.  With
a relatively small population spread over a large area and health
care professionals in short supply, patients often have to travel
long distances to see a doctor.  Doctors are reluctant to
practice in rural areas because they have no help or support from
peers.  Without enough doctors, nurses and health facilities,
building networks of care becomes more difficult, as does the
task of attracting enough health plans to foster competition.

     In inner-city communities, the challenge is almost the
opposite:  crowded cities with culturally diverse populations.
Only a few blocks away from world famous academic health centers,
residents of low-income neighborhoods contend with a laundry list
of health care problems too few doctors and nurses; little or no
access to culturally-sensitive care; high rates of infant
mortality and low-birthweight babies; frequent violence; and
serious health epidemics such as AIDS.

     To serve both communities, the goals of health care reform
are similar:  increase the economic base for health care through
universal coverage, provide discounts to make care affordable,
and create incentives to attract health care providers to the
area.

     The Health Security Act includes new loan programs and
investments to increase the level of service available in
underserved urban and rural areas.  Expansion of the National
Health Service Corps will send new physicians and other health
professionals into underserved rural and inner-city communities,
substantially increasing the supply of doctors and nurses.
Successful programs, such as community and migrant health
centers, will expand to increase the number of places where
people can find care.

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Sidebar - Pg 45

THE MAYO CLINIC
A Model for Reform

     If you went searching for the highest-quality medical care
in the world, you might not immediately think to head to rural
Minnesota. But there in Rochester, you'd find the Mayo Clinic, a
magnet for patients all across America.

     The largest managed care practice in the United States, the
Mayo Clinic is known worldwide for its effectiveness at
diagnosing and treating illness, and for the excellent physicians
who work there. And they've proved that you can control costs and
provide top-flight care, holding cost increases well below
national averages.

     The Mayo Clinic has led the way in encouraging the
development of networks of doctors in rural areas, and linking
rural physicians and regional health centers in order to increase
the availability of high-quality care. These kinds of rural
networks serve as the cornerstone for the Health Security plan's
strategy to make care more available for residents of rural and
remote areas.


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     A new program of federal grants and loans will support
doctors and hospitals in rural and inner-city communities form
their own networks and compete with other health plans.  This
program will link federally funded clinics with other community
providers bolstering their skills to coordinate care, negotiate
with health plans, and form their own health plans.

     The Health Security plan -- by supporting the creation of
new clinics and offices and renovating and converting existing
clinics and offices -- will ensure more and better places to seek
care in these areas.  In addition, it will improve the level of
care -- and reduce isolation -- for urban and rural residents.
This will be done by linking members of the practice networks
with each other and with regional and academic health centers
through the development of more sophisticated information
systems.

     Two new programs will overcome barriers to care for
hard-to-reach, isolated, or culturally-diverse populations.  One
will support school health services for adolescents.  Another
will support transportation, child-care, translation, outreach
and follow-up services for those in need of care but who are not
being served by current programs.

     Hospitals, clinics, doctors and health professionals who
traditionally serve in these areas are also eligible for
designation as "essential community providers", gaining special
protections during the implementation of health reform.  To help
these key providers adapt to the changes in the system after
reform, the Health Security Act requires health plans to contract
with essential community providers for five years to enable them
to continue to serve the residents in these rural and urban
communities who depend on them.