Academy Emphasizes Function Language in Health Care Reform

The Academy played a pivotal role in discussions with the office of US Senator Tom Harkin (D-IA), a senior member of the Senate Health, Education, Labor and Pensions (H.E.L.P.) Committee around health care reform legislation and initiated discussions on the inclusion of “function” in the legislation. This was a major contributing factor in the committee’s decision to insert “rehabilitation and habilitation services” as one of the categories to be covered in the basic benefits package under the bill. During markup of the bill, Republicans argued that provisions of the bill related to prevention may not necessarily improve health. Republicans also argued that a public health fund established in the bill was too costly.

Likewise, the same language appears in the House health reform bill under “minimum services to be covered.” The House bill has been somewhat controversial regarding Medicare provisions, employer mandate language, and a provision to establish a public insurance plan option. House Democrats focused on creating “a level playing field” between a public option plan and private insurance options through a health insurance exchange projected to be completed by 2013. The exchange will include guaranteed issue, modified community rating, and 2-to-1 age rating. It also includes a payroll-based small business exemption. Pricing will be based at the local (not national) level.

The House bill includes both an employer and individual mandate. The self-employed will be included with individuals. Insurance companies with existing plans will have a five-year phase to implement the bill’s changes. A new “Benefits Commission” will be created to define the contents of four benefit categories: Basic, Enhanced, Premium, and Premium Plus. Insurers would have to offer a Basic package in addition to any others; they can only provide add-ons to the Premium Plus package. Medicaid would be expanded to cover everyone up to 133% of poverty and provide subsidies from 133% to 400%.

The bill also includes the previously announced permanent fix to the Centers for Medicare and Medicaid Services’ sustainable growth rate used to pay physicians. A primary care “bucket” will grow at 2% per year and a specialty bucket will grow at 1%+ per year. Notably, the means to pay for the entire bill are still left undecided.

The Academy delivered the message that it strongly supports health care reform that provides greater access to insurance, eliminates health status or disability as a factor in determining insurability or premium levels, and emphasizes coordination of care for acute and chronic illness and disabling conditions in children and adults. Further, the Academy believes that health care reform will not achieve its promise if public and private insurance do not include benefits that improve, restore, and maintain function and maximize performance. A new health care system must help patients function independently and enhance their quality of life.

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