Defining Essential Health Benefits
Transcript for:
Defining Essential Health Benefits MS. DIANE REHM
10:06:56
Thanks for joining us. I'm Diane Rehm. Last month, Health and Human Services Secretary Kathleen Sebelius made a surprise announcement. States would get to decide which health care benefits are essential and deserving of insurance coverage under the new law. The secretary explained that coverage that works in Florida may not work in Nebraska.
MS. DIANE REHM
10:07:31
Joining me in the studio to talk about the implications of the new policy: Judy Feder of the Urban Institute, Joy Johnson Wilson of the National Conference of State Legislatures, Julie Appleby of Kaiser Health News and Joseph Antos of the American Enterprise Institute. Please join us. Your questions, comments, 800-433-8850. Send us your email to drshow@wamu.org. Join us on Facebook or Twitter. And all this week I shall say Happy New Year to you.
MS. JULIE APPLEBY
10:08:25
Yeah, Happy New Year.
MR. JOSEPH ANTOS
10:08:25
Happy New Year.
MS. JOY JOHNSON WILSON
10:08:25
Happy New Year.
REHM
10:08:26
Thank you. Julie Appleby, tell us about the Affordable Care Act and what it defines as essential health benefits.
APPLEBY
10:08:39
Well, the health care law says that most insurance policies offer to individuals and small businesses, starting in 2014, have to cover 10 types of services. And these include things that we're all familiar with, such as emergency room care, hospitalization, wellness services, that type of thing. It also includes some things that some people who currently buy their own insurance might not have, such as prescription drug coverage, maternity care and mental health services.
APPLEBY
10:09:07
But aside from those 10 broad categories, the law did not get into details on the specifics and leaving that up to the secretary of Health and Human Services. So that, of course, raised a lot of speculation about, well, what will the secretary do? Will it be very specific? Will she spell out exact treatments that have to be covered and how many visits you can have? -- that type of thing. So there's a lot of speculation about how this would come down.
REHM
10:09:33
And so what did she do?
APPLEBY
10:09:35
Well, last month, in a move that surprised a lot of people, the secretary released this bulletin that essentially gives states much of the power to decide what essential benefits will be included. So states are going to develop these packages based on one of four different options spelled out by the HHS secretary, which are based mainly on what's already being offered in the states. And those options -- stick with me here-- they -- there's four.
APPLEBY
10:10:00
They can choose either benefits offered by the largest HMO in the state, benefits offered by one of the top three by enrollment plans offered to federal employees, one of the top three by enrollment offered to state employees or one of the top three offered to purchase by small businesses in that particular state. So this gives people a little bit more of an idea of what's going to be offered, but there's still a lot of uncertainty because the states now have to pick one of these.
REHM
10:10:26
And what was the rationale behind her decision?
APPLEBY
10:10:32
The secretary said that she wanted to give states flexibility in designing this package. And a lot of the policy experts that I've spoken with say that this is just part of the way that the Obama administration has been handling this, giving states a lot of flexibility, giving them the choice. So I think that was the main reason that they gave for doing it.
REHM
10:10:49
Did it take some of the heat away from Republican arguments about choice?
APPLEBY
10:10:57
Well, sure. There has been some discussion that the health care laws take over by the federal government. This puts it right back in the states, lets the states decide. The bulletin also did not have to include financial calculations, how much would this cost. So that removes potential factor for the upcoming election as well because, now, the states will pick. And the states will be choosing, and that will also affect the price.
REHM
10:11:23
Julie Appleby, she's senior correspondent for Kaiser Health News. Joy Johnson Wilson, how did the states feel about this kind of shift to choice for the states?
WILSON
10:11:42
Well, actually, the states had been pressuring the administration to move up the timetable for establishing the essential benefit package because there is a provision in the law that says -- that addresses state-mandated benefits. And it says that any state-mandated benefit that would be outside of what the secretary describes as the essential benefit package would have to be paid for by the state, either by making a payment to the plans or to the beneficiaries, to make them whole.
WILSON
10:12:17
And under the timetable prior to this bulletin, the essential benefit package would not have been final until probably the summer of this year when most states would have already completed their 2012 legislative session. So this was not workable, and we said something needed to be done to move that up because appropriations people can't deal with a proposed rule and what that might cost. They need to know how much state money was on the table before they adjourn, and so this does that.
REHM
10:12:53
So states that were kind of on the fence about this can now start moving forward?
WILSON
10:13:01
Well, even states that weren't on the fence had this problem of not being able to say what the budgetary impact of the essential benefit package would be on the states. So it helped states that wanted to move forward and have this as a barrier. It also helped in states where people were maybe on the fence and said, and we have this problem. So it eliminates that problem.
REHM
10:13:27
So what happens if a state does not designate a benchmark plan?
WILSON
10:13:35
Then the secretary will designate the benchmark as -- I believe the default is the small group, the small group plan in that state with the largest enrollment. And the thought behind that is that that would include all the state-mandated benefits.
REHM
10:13:55
This gets very complicated. Joy Johnson Wilson of the National Conference of State Legislatures. Judy Feder, do you think this was a surprise move on the part of the Obama administration?
MS. JUDY FEDER
10:14:15
Well, we've been -- heard that it's perceived -- it surprised some. The political challenge the administration faced was that it would be criticized if it had a very precise benefit package. It's not a surprise as others have said in that the administration is being very careful to challenge those who would say that this is a federal takeover. I've heard some say in this anti-government environment that people tend not to think of states as governments. And so choosing to rely on the states take some of the punch out of the charge that this is a big government takeover.
MS. JUDY FEDER
10:14:58
So when you look at lots of what the administration has done, there is a tremendous reliance on states in the implementation of this law and an avoidance of national decisions.
REHM
10:15:09
And, Joe Antos, does this new policy make the health care law better?
ANTOS
10:15:17
Well, it probably makes it a little more feasible, but the fact is that the issue here is not government in general. It's federal government. I think that's what this move actually addresses, and it's a smart political move for President Obama's Democratic base. He's not going to get into a whole bunch of arguments about -- from various supporters who have specific health benefits they want named very specifically. That's a good thing for any sitting president to avoid, but the states will be disappointed.
ANTOS
10:15:53
There will be a regulation. This is not a regulation. This is a press release. It's called a bulletin. It's a press release. It is an early warning, and it is always possible in the regulatory process, which probably won't occur until late this year or 2013 -- it's always possible for things to change.
REHM
10:16:11
Judy Feder.
FEDER
10:16:12
Actually, I'm surprised that Joe -- Joe, I'm surprised that you say this is -- avoids a problem with the base because, actually, consumers, in particular, were looking for national standards. Consumers' concern in the implementation of this law is that they get both certainty and guarantees.
REHM
10:16:32
Well, bring this down to a practical level. Help me to understand where the uncertainty lay and how this does or does not solve the problem.
FEDER
10:16:45
Well, both variations and limits in health insurance policies are a big problem for consumers. I should start with the limits because if you think you're covered for hospital services or physician services or prescription drugs, you want to be covered for what your physician prescribes. And in a lot of the non-group outside the large employer, and even the small employer market, insurance policies can be very skimpy. So consumers are looking to this law to provide them real meaningful insurance protection.
REHM
10:17:18
This based on which they can count.
FEDER
10:17:21
Exactly. Exactly. And when there's variation in benefits that plans can offer, then consumers are often confused and unhappily surprised. There's a lot of push for choice of insurance plans, but the choices are often hard to make because it's very confusing to know what will be covered when you get sick. The greatest certainty and guarantee consumers could have gotten would be a nationally defined benefit package, with certainty that it would be available everywhere all the time. And they didn't get that. So I think there is some disappointment here and some concern.
REHM
10:17:58
Do you agree with that, Julie Appleby?
APPLEBY
10:18:03
Well, I think there were a lot of patient groups that wanted a single national plan. And they're disappointed. That said, this does require certain things. They still -- every plan has to have the 10 broad categories. Many plans people buy, for example, right now, on the individual market, do not cover maternity care, or they might not cover prescription drugs. They will have to under this rule, so...
REHM
10:18:24
And the bottom line, it seems to me, is that if you have states with the authority to decide what's going to be in their plan, you're left with some confusion. Julie Appleby of Kaiser Health News. Short break and right back.
REHM
10:20:05
And welcome back. We are talking about an announcement last month by Health and Human Services Secretary Kathleen Sebelius that states would get to decide which health care benefits are essential and deserving of insurance coverage under the new law. Now, of course, we still have the Supreme Court, which we are going to have to deal with, which may -- could make all of this moot. Julie?
APPLEBY
10:20:45
It could. We'll have to wait and see what happens with the court ruling, but they are looking at the individual mandate and are looking at the Medicaid expansion piece. But we'll have to see what happens with that.
REHM
10:20:55
All right. Here's a posting from Jonathan on Facebook, who says, "Does this approach put additional burden on health insurance companies who have to deal with different policies in different states?" Joe Antos.
ANTOS
10:21:15
Well, they were going to have to do that anyway, so I don't think that's much of an issue. The big national companies -- I won't name them. But the big national companies already operate in different states with different rules, so they're used to this. I think the big issue is, what will the resulting insurance actually cost? And if you'll look at one of the standards -- one of the standards could be the Blue Cross plan that federal employees get. And that plan is already almost $2,000 more expensive than the amount that the president said in another press release. We would see in 2014.
REHM
10:21:54
Judy Feder.
FEDER
10:21:55
Yeah, I think that the -- what we know about variation in insurance policies is that the primary factors that determine their cost are not the variation in the scope of what they cover. The primary variation is in how much cost sharing they charge, how much patients have to pay out-of-pocket when they go to the doctor or experience some medical need, and, actually, this rule doesn't -- or this post-rule...
REHM
10:22:21
Doesn't affect that. Yeah, yeah.
FEDER
10:22:22
Or this guidance doesn't address that, and that's -- in the future, that's an issue of concern, not so much for the total amount cost sharing, but for whether that can vary in ways that charge more for, say, chemotherapy and charge less for doctor visits.
REHM
10:22:40
Joy.
MS
10:22:41
Well, I think in the bulletin they mentioned that the cost-sharing rule is going to come out some time soon, and they do come together. They -- you can't really look at them separately. I -- they -- I think they moved on the essential benefit issue faster because they were trying to get ready for states going into session in January.
REHM
10:23:01
I see. I see. Here's an email from Karen, who says, "Provided the Affordable Care Act is upheld, are there no minimum benefits that all states would have to offer? How long before 2014 will the state health insurance options be available for consumers to look at? And, finally, will states' health insurance policies be transferable to other states?" Judy Feder.
FEDER
10:23:39
Well, the benchmarks are -- which -- although states can choose different benchmarks, there is a tremendous consistency across the board. And, even though our national package wasn't specified, there is a belief that, in most states, if not all, there is a decent minimum. So that is addressed. Exactly when consumers can look at them -- I look to some of my colleagues. Is that in 2013 before they are open? I think they have them available in 2013.
ANTOS
10:24:10
It has to be because…
FEDER
10:24:12
(word?) choose.
ANTOS
10:24:13
Exactly.
FEDER
10:24:14
Yeah.
ANTOS
10:24:14
The exchanges have to be in operation some time in late summer or early fall of 2013 so that people can get their plans, so they (unintelligible).
REHM
10:24:22
And, finally, are these transferable from state to state, Julie?
APPLEBY
10:24:27
I don't know the answer to that. That's a very good question.
FEDER
10:24:29
The transfer of -- there are some rules about being able to sell in other states that I, too, am not up on at the moment. But there is also the potential, which is we've yet to see happen for regional exchanges, in which case they would be offered in an area.
REHM
10:24:46
Julie, going back to something that Judy said, how does the new policy affect what patients will have to pay for co-pays and deductibles?
APPLEBY
10:25:01
We don't know exactly yet because they haven't come out with the rules on co-pays and deductibles. However, if you have a service that's not covered, you are missing paying for that out-of-pocket yourself, and there is also the question of what kind of limits will there be. Will there be -- for example, you can have 20 physical therapy visits a year, for example, or more or less. So those kinds of details are going to vary policy by policy as they do now. That's how it is now on the market.
APPLEBY
10:25:26
So it will affect what people pay in co-pays and deductibles, and, as Joe mentioned, the ultimate package also affects how much the total premium will cost.
REHM
10:25:35
I would think, Joe Antos, that the secretary's announcement makes everything more complicated.
ANTOS
10:25:46
It's hard to make this more complicated. First of all, it's health insurance, so health insurance is inherently complicated. I think the problem is that there just hasn't been enough time for HHS to figure everything out that they want to figure out, so I'm actually sympathetic to the administration in terms of the effort to put anything out. That said, however, I think there's a great deal of overreaching and trying to specify as much as is being specified. By the way, one other point: People who are eligible for subsidies in the exchanges will also be protected.
ANTOS
10:26:21
There are some rules about how much their maximum out-of-pocket cost could be in a year, so, in fact, it is even more complicated than we've already let on.
REHM
10:26:32
Explain how those exchanges are going to work, Julie.
APPLEBY
10:26:37
These exchanges, you can sort of think of them as an online marketplace for health insurance, a little bit like a travel website or that type of thing. Consumers are going to be able to go onto them, look at plans, compare plans. There'll be standardized four different types, you know, bronze, silver, gold, et cetera, et cetera, and they'll be able to shop for coverage on these exchanges. And each state is going to be setting one up. And if a state chooses not to or cannot, the federal government is going to have fallback exchange where people could shop in that state for coverage.
REHM
10:27:05
And, Joy, how likely would states be to choose the higher, more expensive plans?
MS
10:27:15
Well, it's hard to say. I think they're now all looking at what their -- the array of options are. I think it's important to note this is a transitional policy, so it's only for the first two years. And then there's going to be some re-looking this whole policy. So some state-mandated benefits could, in 2016, be dropped out of the essential benefit package.
REHM
10:27:43
I see.
MS
10:27:44
So there's a lot to think about. And, I think, since states just got this and they haven't been in session, they've got staff taking a look at it. And then they'll be presenting to the legislatures of the range of options and some idea of what picking one over the other might do.
REHM
10:28:04
And does the new bulletin, perhaps, Judy Feder, inevitably lead to a higher premium for consumers?
FEDER
10:28:16
No, by no means.
REHM
10:28:18
By no means.
FEDER
10:28:19
By no means. I mean, these benefits standards are -- as Joy said, these are pretty much a reflection of you can keep what you've got. These are keeping in place, or allowing states to keep in place, what people are most accustomed to. There are some improvements in benefits, as Julie said, that may have modest effects -- modest effect on premiums, so inclusion of mental health, inclusion of habilitation services for people with disabilities about which there are still some vagueness.
FEDER
10:28:54
So some improvements that may have some modest effect on premiums, but these, across the board, are not going to increase premiums.
REHM
10:29:01
Julie.
APPLEBY
10:29:02
Let me also add that these rules apply to policies sold to individuals and small businesses. They do not apply to self-insured companies which are most of the large employers. So if you have coverage through a large employer, this essential benefit bulletin does not affect you. However, most large employers already offer this type of package of benefits.
REHM
10:29:23
So small employers are going to be more affected than large employers? Should HHS have set a limit on the cost of minimal essential elements within a package, Joe?
ANTOS
10:29:48
Well, this is a really complicated question. There is something called actuarial value that's at play here, and this is another thing that wasn't specified in the bulletin. So, really, HHS, so far, has not really addressed the cost issue. And, in fact, I think they're incapable of it. You really need to have a better idea what the insurance package is and then raise the question, how much of the subsidy is going to be?
ANTOS
10:30:21
Who's going to be eligible for the subsidies, especially who's not going to be eligible for the subsidies? And where is -- not that scientific level, but rather where is that political, social, cultural level that you want to set your policy at? That's a very difficult question.
REHM
10:30:37
Julie.
APPLEBY
10:30:37
Early on in this process, the secretary asked a blue-ribbon panel at the Institute of Medicine to make recommendations on how to structure this essential benefit package, not what should be in it specifically, but how to do the process. And one of their recommendations was that the secretary set a premium target and sort of craft the benefits around that, and their premium target was based on what a small employer might be expected to pay in 2014. That didn't happen.
REHM
10:31:04
So are you going to have time for public comment, Judy?
FEDER
10:31:10
Oh, there's definitely time for public comment. They're looking for comments 'cause they've left a number of questions open. But going back to this cost issue, I think, consistent with what Julie just said as an IOM recommendation, since the state can choose as a benchmark the most common small employer plan -- they're quite consistent with that -- again, most plans are offering pretty much the same benefits across all these plans -- benchmarks.
FEDER
10:31:38
So I don't think that the issue is in any way that HHS skirted a cost issue. What I believe is that benefit design is not the way to address costs. The way to address cost is in terms of changing the way in which we are paying providers, doing a better job of coordinating care. The argument is that we need to emphasize services that keep people out of hospitals rather than hospitalize unnecessarily. Benefits -- people have a right to expect good, comprehensive benefits. And we hope that this guidance is on a path to that, but there are decisions yet to be made.
REHM
10:32:17
But if you have time for public comment and if that public comment leads a majority of people who are commenting, saying states should be consistent across the board with the kinds of benefits they offer, how likely is that, Judy? Not going to happen.
FEDER
10:32:39
Not going to happen. This is -- this decision is part of a cautious implementation policy, sensitive to the states' concerns about what they would have to pay if the benefits that they now offer or require were not covered, the mandates in the essential benefits. So that's not going to happen.
REHM
10:33:00
Judy Feder of the Georgetown Public Policy Institute. And you're listening to "The Diane Rehm Show." And, by the way, the public comment period has been extended to the end of this month. Let's go to the phones, 800-433-8850. Send us your email to drshow@wamu.org. First to Mt. Dora, Fla. Good morning, Ross. You're on the air.
ROSS
10:33:39
Well, thank you, ma'am. As a physician assistant who has spent the last 25 years jousting with the insurance companies to help people get the care that they really need and deserve, it's important that folks understand three quick, important points about what's going on in the first place. Although they have changed the -- who gets to say who the benefits are, they haven't changed the fact that this bill was being funded through -- not a tax system through the IRS.
ROSS
10:34:16
And they haven't changed the fact that this is basically being run by actuaries who are, by definition, professional gamblers and are not likely to wind up paying near as much as the government would like them to be paying for whatever service they get.
REHM
10:34:34
What do you think about that, Joe Antos?
ANTOS
10:34:37
Well, as I think Judy Feder commented, the -- this guidance doesn't address coverage, which specifically means what will the insurance company agree to pay for. And it does not -- of course, it doesn't cover out-of-pocket costs. You need to have both of those elements. And, in fact, any kind of insurance, including Medicare, has exactly the same kind of process.
ANTOS
10:35:07
With Medicare, our national health insurance program, we have, essentially, insurance companies who are agents to the federal government, making decisions on a daily basis about whether a specific service is appropriate and can't be compensated through the program.
REHM
10:35:24
And I must say, I wouldn't refer to actuaries as gamblers, by the way. As I said, the public comment period extends to the end of this month, and a link to the HHS bullet news on our website at drshow.org. Public comments can be sent to -- pardon me, to HHS by email. That address is essentialhealthbenefits@cms.hhs.gov. Let's go to Cazenovia, N.Y. Good morning, Aaron.
AARON
10:36:17
Good morning, and Happy New Year, Diane.
REHM
10:36:18
Happy New Year to you, sir.
AARON
10:36:21
I wanted to make two short comments that it seems almost a no-brainer that if everyone in the country participates in insurance for health care that we distribute the cost across the board and across age and that that ought to work in favor of health care for everybody.
AARON
10:36:44
And the second thing is that by making private health insurance affordable in some way so that we could separate out and finally free health care from a particular job that want us in, with possible exception of workers' compensation, which, you know, makes sense, you know, it would seem that that would free up a lot of people's live for being wedded to jobs they don't want...
REHM
10:37:14
All right. Judy Feder, quick comment, please.
FEDER
10:37:18
Good points. The law does do those things, and that was the goal. So I think you are quite right, Aaron. And I would just add that having everybody by brings everybody together, the sick and the healthy, and that's what this is about.
REHM
10:37:32
Judy Feder of the Urban Institute and professor and former dean at the Georgetown Public Policy Institute. More of your calls when we come back.
REHM
10:40:04
And right back to the phones as we talk about a new memo released by Health and Human Services Secretary Kathleen Sebelius last month. You can find that on our website at drshow.org. To Bowling Green, Ohio. Good morning, Bob.
BOB
10:40:31
Yes. Good morning. A little while ago, the one commentator mentioned -- used the phrase decent minimum benefits. I wonder if she's actually looked at benefits that a lot of people have. For example, several years ago, I had coverage through one of the big-box home improvement stores. It was extraordinarily expensive. It had very low annual limits so that when I had a mild heart attack, only a portion of that was covered. And I am still paying through the nose. I do not feel that I had -- that there currently exist decent minimum benefits.
REHM
10:41:09
Julie.
APPLEBY
10:41:10
There are plans out there that don't cover very much, and there are minimum benefit plans. However, the new law does limit those. There's annual limits right now on how much they can cut. They can't cut you off after -- they have to spend at least $1.2 million on you this year. They can't have a minimum benefit below that. However, the Obama administration has made some exceptions for some large companies and some union plans and some other plans that allows these smaller packages to continue on the theory that it's better to have some insurance than none at all.
FEDER
10:41:43
But that's time limited.
APPLEBY
10:41:44
And those are time limited.
FEDER
10:41:45
That's time limited. And so the specifics, the annual limits, the lifetime limits, dollar limits on the benefits in your policy, those -- you'll be pleased to know, Bob, those are going away. That's -- but that is over time, and the law has to stay in effect in order to do that.
REHM
10:42:00
Right. Good luck to you, Bob. Let's go to Cleveland, Ohio. Good morning, Evelyn.
EVELYN
10:42:09
Good morning, Diane. Thanks for taking my call.
REHM
10:42:11
Of course.
EVELYN
10:42:12
I am a nurse practitioner and -- but I'm no longer working because I have had a stroke, and so I'm on disability.
REHM
10:42:21
I'm sorry.
EVELYN
10:42:23
Now -- I thank you. And I have two questions. Now, what is going to be the impact on something like Medicaid for patients who are on Medicaid, number one? And, number two, currently, I am on -- I'm receiving disability pay through what's called OPERS, which is Ohio Public Employees. So I receive, you know, my insurance through them. So what will be the impact on that? And I would -- you know, I'd appreciate having comments from the -- from your people there.
REHM
10:43:01
All right. Thanks for calling. Joy.
WILSON
10:43:04
On Medicaid, the essential benefits applies to the Medicaid program. Medicaid is -- will be part of the exchanges, and so the biggest change in Medicaid is that there is an expansion to people who are childless adults with incomes below 138 percent of poverty. So in most states, those people would not have been eligible for Medicaid coverage, and now they will be.
REHM
10:43:36
What about disability?
WILSON
10:43:40
People who are on SSI, for instance, which is the public disability program, are categorically eligible for Medicaid, and that would continue. With state employees, most state employee plans are self-insured. And so the self-insured plans have some different aspects than the plans that are inside the exchange. Most of them do cover what's pretty much called the essential benefit package, and I think we'll have to wait and see if states make any changes to their state employees' benefits programs.
REHM
10:44:20
How much is all of this going to cost the states themselves, Joe?
ANTOS
10:44:28
Well, Medicaid expansion could be pretty substantial. Once things settle down in a few years -- well, for the first few years, there's an enhanced federal match, and let me explain that. Right now, the Medicaid program is partially funded by the federal government, partially funded by the states. I think the average amount that the federal government pays is about 57 percent of the total cost. For the newly eligible people starting in 2014 -- and correct me here, Joy, if I've got this wrong -- the federal contribution will jump to 90 percent?
WILSON
10:45:07
No, 100.
ANTOS
10:45:08
Hundred percent. But if that...
WILSON
10:45:10
A hundred for eight years.
ANTOS
10:45:11
For eight years, and then, eventually...
WILSON
10:45:13
Ninety.
ANTOS
10:45:13
...it comes back down to 90.
REHM
10:45:15
I see.
APPLEBY
10:45:15
Well, it's only three years.
FEDER
10:45:16
Well, 90 for the first -- oh, it's 100 for three years and then 90 for the...
APPLEBY
10:45:20
Then it goes -- yeah.
FEDER
10:45:22
Well, it goes to 90 till the end of the decade. And then it's left open, so most of the new costs are borne by the Feds.
ANTOS
10:45:29
Right.
REHM
10:45:30
All right. And here's an email from Rob in Virginia, who says, "I've had a small business in Virginia for 40 years and have been the area's largest HMO since 1993 -- been with them. After large increases every year for the last five years, my health care premiums went up 152 percent in 2010, $51,000 a year for a family, $42,000 for a couple." My jaw is dropping open. Julie.
APPLEBY
10:46:16
My jaw is dropping open a bit, too. Wow. That's a lot. I have written a lot about people who buy their own insurance or for their small businesses. And the rates can increase every year, sometimes a couple of times a year, so that is not uncommon. That amount is huge. I think the average around the country for a family plan that employers buy is around $15,000. It's possible that he has some folks in his plan that are sick, or perhaps there's been a premature baby born to one of the workers at his company that would raise it.
APPLEBY
10:46:46
If he stuck with the same insurer for all these years, that could also be part of the reason why he is seeing such a large increase. He may want to shop around if he can. There may be reasons he can't get coverage from another insurer.
WILSON
10:47:00
But the law actually makes this a lot better potentially for this...
APPLEBY
10:47:03
In 2014.
WILSON
10:47:04
In 2014, absolutely.
REHM
10:47:06
All right. To Fort Wayne, Ind. Hi, Richard. Happy New Year.
RICHARD
10:47:12
Good morning, Diane and the panel.
REHM
10:47:14
Good morning.
RICHARD
10:47:16
There's a couple of things I would like to address. I'm in the business -- I'm a broker agent, OK? And I think that the decision that the HHS secretary made was -- it's just -- I don't think it's a good decision. You know, you have states that are not on the same mindset as the Obama administration, so I think there's going to be some resistance there as far as the type of minimum care or minimum benefits that's going to be provided. You know, so I think there should be some type of standard across the board.
RICHARD
10:47:59
And I think that would make it, you know, fair for everyone. You know, I'd like to see something like that -- what they offer with Medicare, with the recipients -- beneficiaries receive like Medicare Advantage, something like that, where, you know, there is some cost sharing involved, and there are the cap because I think when this is -- when all this is implemented, you know, I don't want to see individuals still struggling.
RICHARD
10:48:34
And even though I do -- again, I am in the business, and the insurance business is going to be there. The -- another thing is, too, is that for the wellness, I -- you know, I see wellness packages, and I see them across the board. And there needs to be a standard of benefits in these wellness packages. And these package of -- the theory is that the packages should provide preventive maintenance.
REHM
10:49:05
All right. Sir, thanks for calling. On that first point, Joe Antos, is it fair to have some states define what those basic elements are going to be and have other states, which may not be as generously inclined, to define them another way?
ANTOS
10:49:31
Well, again, all that's really at stake here is the definition of benefits...
REHM
10:49:36
Right. And that...
ANTOS
10:49:37
...not the financial part of it, right.
REHM
10:49:38
OK.
ANTOS
10:49:39
And so -- and as the HHS report says, they did a survey, and they found that the kinds of benchmark plans that they suggest to states are very similar across state lines. So I -- it seems reasonable to me. It does makes sense that you move the decisions closer to where the market is, and at least, at the state level, they know something about their cost conditions. They know something about the conditions in their health market, and they know something about what their lower-income people can afford.
REHM
10:50:24
Joy.
WILSON
10:50:25
And I think it's also important to note that when the president promised that you could keep what you have, there are some states that have state-mandated benefits that would probably not be in a national program to start. And so at least during this transitional period, those people will hold on to those benefits while there is an overall assessment of what an essential benefit package is.
REHM
10:50:52
Judy.
FEDER
10:50:53
I just think it's important to note that there are some risks here. And so, for example, consumers groups are concerned that under some of the benchmark plans that, in prescription drugs, for example, a state could choose a benchmark plan that doesn't include important cancer drugs, age drugs, drugs that people who are very sick may really need to count on. That's a very real concern with very real financial implications.
FEDER
10:51:21
So even though the general thinking -- but there is a lot of uncertainty. There's a lot of ignorance about what states are actually offering or what plans are in different states. Even though there is a general view that this is likely to be a good broad package, there is still some concern how it will play in some states.
REHM
10:51:38
And, Julie, what about that wellness package?
APPLEBY
10:51:42
I think that what folks are going to have to look at is it's going to vary. Like Judy was saying, these packages are going to be different in various parts of the country, and I think it's going to be up to whose going to police that. And I think it's going to be up to journalist to help cover this, who -- what's being covered, what's not being covered. And it's going to be up to the states, but it's kind of unclear exactly what's going to be in it.
APPLEBY
10:51:59
And then the wellness package, some of that is spelled out. If you remember in the law, it does say that preventive care is covered without a co-pay and that preventive care is often determined by what the U.S. Preventive Services Task Force has listed as preventive service.
REHM
10:52:12
Such as?
APPLEBY
10:52:13
All things like mammograms, for example, certain other kinds of cancer screenings, that type of thing. Vaccinations are included in that as well.
FEDER
10:52:21
Just a couple of other concerns, the cap on out-of-pocket spending, that exists. So the caller can know that, again, with the implementation of the law, there is a cap on out-of-pocket spending. On wellness, there is also -- there are some concerns about rewards to exercise and some other kinds of things. And I don't know whether it was the caller's concern, but there is a concern that it is a way to let healthy people who are able to do a lot of exercise get benefits and those who aren't, not so much. So there are some concerns, and the call for standardization, there was a good one.
REHM
10:52:54
All right. And you're listening to "The Diane Rehm Show." To Dallas, Texas and Eddie. Good morning. You're on the air.
EDDIE
10:53:04
Thank you. Thank you for covering such an important topic. I'm on the board of the public health system here in Dallas, and I would just have to say I would love it if the administration would have come out with a specific benefits plan 'cause it's likely to be significantly better than our state would do that for their own devices. But, politically, I completely understand why they would take this route.
EDDIE
10:53:23
And if it will helps save our health reform itself, then it's a cost well worth it to me. My deeper concern, though, is a more basic one and that this show is an anomaly in that you've got public media investigating these issues in depth. If you look at what's happening in Iowa and other places, and what I think is going to happen over the course of the election, we don't hear people getting into the details of these kind of very important issues.
EDDIE
10:53:46
So we have all kind of shorthanded facts on Obamacare and ad hominem attacks on health care reform in general. So my question is, how do we get more of the national media -- national political media to cover this issue more intelligently and deal with more of the specific issues...
REHM
10:54:04
Eddie, all I can do is do what we do every single day: try to go into these issues, make sure we have wonderful guests who know what they're talking about. But it's also up to people like you to make sure to ask questions about decisions that are likely to be made by various candidates, including President Obama when the true debates begin. Thank you so much for your call. Let's go now to Miami, Fla. Good morning, Mark. You're on the air.
MARK
10:54:58
Good morning. And thank you very much for having me and for taking such an important issue on the radio.
REHM
10:55:01
Surely.
MARK
10:55:03
My question is pretty simple. I'm in my 30s, middle of my 30s. And most of my life, I didn't have insurance. I paid for the things that were necessary to pay for. When I race motorcycles, I decided to take catastrophic coverage, which is very cheap. It's about $80 a month. If this mandate comes up, I am not going to participate. I'm not going to pay it. If I am fined, I am not going to pay the fine. What is going to happen to me?
REHM
10:55:32
Judy.
FEDER
10:55:33
Well, I hope you will stay healthy because, if you don't have health insurance, I worry for you.
REHM
10:55:38
Well, but if...
FEDER
10:55:39
But you'll pay the fine, and that's what you'll do. And I definitely hope you'll be in a minority because insurance can only work if we're all in it together.
REHM
10:55:49
But, Joe, aren't we going to pay for Mark if he decides not to pay for himself?
ANTOS
10:55:58
Certainly seems that way, but Mark doesn't -- isn't aware that there's also something called the Young Invincibles policy that may be very similar to the kind of thing that he's already buying and that he may be comfortable purchasing.
REHM
10:56:12
Hey, Mark, how do you feel about having all of us pay for you?
MARK
10:56:18
I do not wish -- it's a very valid point. I do not wish for anybody to pay for me.
REHM
10:56:22
But that's what happens
MARK
10:56:22
And my question was more direct...
REHM
10:56:24
That's what's going to happen if you decide not to buy into any policy. You know, that's a little preaching on my part, but it is the fact. And I think everybody has to be aware of it. I want to thank you all so much for joining me this morning, Judy Feder, Joy Johnson Wilson, Julie Appleby, Joseph Antos and, of course, you, our listeners. Thanks for joining us. I'm Diane Rehm.
ANNOUNCER
10:57:01
"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Denise Couture, Monique Nazareth, Nikki Jecks, Susan Nabors and Lisa Dunn, and the engineer is Tobey Schreiner. A.C. Valdez answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our email address is drshow@wamu.org, and we're on Facebook and Twitter. This program comes to you from American University in Washington. This is NPR.
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