Monday, May 7, 2007

Now is the time.....

Between now and Saturday, May 12, 2007, is the only real opportunity to voice your concerns to the 208 Commission through the public comment. After May 12, there is no opportunity for public comment before they select the 3 to 5 proposals, which they will do at public hearings on May 17 and May 18. These 3 to 5 proposals will be the ones submitted to the state legislature next January for its consideration. This means that you and your voice could be heard by the legislature through the commission.

There are currently 11 proposals being considered. I have summarized the 11 proposals briefly below -- at the end of this post.

Only one of the proposals recommends deregulation of the insurance market and of Medicaid. That proposal was submitted by Brian Schwartz, PhD, and his full proposal (worth reading) is called FAIR (Free Markets, Affordability and Individual Rights). (You must download it - it's toward the bottom of the page).

The Commission numbered each tendered proposal -- and the FAIR plan is number 21. The other plans include individual mandates, insurance company benefit mandates, insurance company guaranteed issue and community rating mandates, employer mandates, provider mandates, or some combination of the above. My summary of all eleven is provided at the end of this post.

The Commission is requesting comment on 2 issues related to these proposals:

1) What are the one or two most important features that you feel must be included in any Colorado health care reform?
2) What is the most important principle that should be considered in any reform effort?

There are two ways to provide comment to the 208 Commission. 1) You may submit a comment in writing by e-mail to It is crucial to send your comments this way. Any comment sent to this address will be posted on the Commission website and distributed to all Commissioners for review in advance of the May 17-18 meeting. But the e-mail must be received by May 12. Comments sent to individual commissioners, or received after the deadline will be ignored.

Alternatively, there are five meetings planned across the state this week -- May 10 and May 12 -- for public comment and where you have the opportunity to speak before one or more commissioners. They still want you to submit written testimony at the time of your oral presentation.

This is the last opportunity to express your opinion about the most important principle (and features) to be used to select any proposal. This is the time to speak about capitalism v. government control, the individual rights of doctors and other providers v. the needs of some patients, and freedom in medicine and health insurance v. insurance mandates and other instances of government force.

To be effective to the Commission, any written (or oral) comments must state specifically ONLY the principle and or features that are most important to health care reform, and to give specific reasons for that choice. They are not interested in your advocacy or rejection of any particular proposal.

Some examples of written comments to the 208 Commission might be
  • The most important feature to include in any health care reform would be to eliminate all mandates -- whether they require individuals or employers to purchase health insurance, or whether they impose benefit packages on insurance companies, or impose mandatory guaranteed issue and/or community ratings of insurance companies; or any mandate on the care or treatment (including the cost for that care) provided by any health care provider. Mandates violate the freedom of contract between individuals, doctors and insurers. They also increase the cost of health insurance policies for the healthier citizens by subsidizing the cost of those who are not as healthy. OR,
  • The most important principle to consider in any health care reform would be that only capitalism can provide the best quality of medicine and health insurance at the lowest possible price. For example, the United States leads the world in innovative, new science and technology in medicine because of its tendency towards market based solutions, not in spite of them. Government controlled medicine and insurance advocate the status quo, and are resistant to change. To continue to have better and better technology to save more premature births, to enhance the quality of the lives of diabetics, heart patients, cancer victims old age survivors, as well as countless other conditions, we must turn to capitalism and capitalism alone, for its infinite choices and solutions, made by individuals in a free market. OR,
  • The most important principle to consider is that government involvement in medicine has caused the problems we face in health care today and we need to get government out of medicine. For example, the 1942 IRS ruling distorted the market to favor employer-purchased health insurance policies over individual purchased ones, thus taking the responsibility for the purchase of health insurance from the individual, eliminating portability, transparency of the costs of medical services and health insurance, and encouraging too much coverage for routine care, while discouraging catastrophic care coverage. Another example is EMT ALA, which required all hospitals with emergency rooms (and their doctors) to treat any person, regardless of ability to pay, who believed they had an emergent health issue. This caused doctors and hospitals to treat some people, while getting paid nothing. This in turn caused hospitals and doctors to charge others who could pay more, and caused some hospitals and doctors to stop providing care -- to close emergency rooms and to stop practicing at hospitals with emergency rooms. We need to eliminate provider mandates. OR,
  • The most important principle of any health care reform would be respecting individual rights of doctors, insurers, employers and individuals. Doctors and hospitals must be free of mandates that require them to participate in any program (e.g., EMT ALA). Insurers must be free to contract and provide whatever benefits they deem profitable or appropriate (eliminate all mandates including mandatory guaranteed issue and community rating). Employers and individuals must be free to purchase health insurance at whatever level they deem appropriate (e.g., high deductible - HSA, basic minimum, catastrophic only, etc.). No one has a right to force others to provide him or her health care or health insurance -- even though many governments have treated both as temporary privileges -- granting benefits which it can then take away depending on cost, majority vote, or other illusory standard
Again, these are examples. The crucial thing is to pick the most important principle for health care reform, or one or two features that are important to consider in health care reform, and make them your own. Feel free to use any of these, expanding or narrowing them to suit your situation. There are many more specific examples for any principle or feature that could be used.

NOW IS THE TIME to send your comments to the 208 Commission. The Commissioners need to understand what is important to you, what principles are crucial to you and how those principles are manifested in features of the various proposals.

To assist you in understanding the essential features of all eleven plans being considered for submission to the legislature, I have summarized them below. You may read the full proposals at the 208 Commmission website by downloading any or all from this page. I used the commission number for each plan. These 11 proposals are as follows:

#21 – FAIR (Free Markets, Affordability and Individual Rights) proposed by Brian Schwartz, PHD. Plan proposes to lower cost of health insurance by eliminating all insurance benefit mandates, thus allowing people to obtain less coverage for fewer dollars. Eliminates single-group of one which eliminate guaranteed issue and community rating for that market.
Seeks to encourage high deductible HSA health insurance plans.

Medicaid Reform seeks to transfer more enrollees into private insurance market. It also uses cost-sharing to eliminate over-consumption of some Medicaid services. He also advocates reduction of asset sheltering for long term care in Medicaid. He also advocates increasing access to home care and, most provocatively, to allow Medicaid to compete for funding with voluntary charities in the private market.

#16 -- The Colorado Health Services Program, proposed by Health Care for All Colorado Coalition – is a single payer, publicly financed program. It covers all primary, preventive, specialty, surgical care, automobile and work-related injuries, prescription drugs, mental health services, chiropractic, dental, basic vision, audiology, home health and hospice services, among others. It states that all providers and hospitals will be paid the same for the same level of service, thus eliminating the drive for profit in determining the quality of care. It is explicitly egalitarian and states that every resident has equal access to program benefits. There is no opt-out provision.

It calls for a statewide, fully integrated information technology network to track outcomes, utilization and expenditures. Removes profit motive from financing resulting in a truly egalitarian health care system. Would create the Colorado Health Services: a non-profit government "insurance company," administered and governed as a public utility with five districts and it would be strictly regulatory - no outside supervision or control. All of its decisions final. It would also determine malpractice, but allow its findings to be public in malpractice litigation in a court of law.

#12 – A Plan for Covering Colorado, proposed by the Committee for Colorado Health Care Solutions – requires a single insurance pool – in which all insurers would be required to participate and would be mandatory guaranteed issue and community rated. All individuals, including all state employees, and employers will be mandated to purchase insurance through the single pool. Employers would be mandated to pay a portion of the employees' health insurance or pay an assessment to the state per employee. Individuals (and employers) would be limited to opt for one of 6 to 10 standardized benefit plans. Policy mandates would include a list of essential services, but could include options of type (PPO or HMO), choice of provider panels, and amounts of co-pays or deductibles allowed. Employers required to allow workers to pay their share of premium through payroll deduction. So employers become the enforcement mechanism -- they collect the premium and forward to the state.

This single insurance pool wold be administered by new public authority – Colorado Health Insurance Purchasing Authority. It will define benefit packages, define and periodically update a standard set of benefits based on effectiveness and cost, define and certify “high-value" providers, define subsidy and premium assistance requirements to be provided to low to middle income individuals. Consumers with premium assistance can opt for only 2 plans, with one an HMO. Authority will also decide guidelines for performance of providers, and of course, determine the amounts paid to the providers.

#11 – Community of Caring proposed by a coalition of CCHN, CCC, CA and CBHC. Individuals have mandate to purchase adequate health insurance; there is also an employer mandate to contribute to employee coverage; Insurers must guarantee insurance regardless of health according to community rating. The plan will provide subsidies to low-income and small businesses and expand Medicaid to more people. Benefits will include preventive care, routine medical services, maternity, diagnostic testing, hospitalization, emergency care, outpatient surgery, mental health and substance abuse treatment, physical, occupational and speech therapies; in-home, hospice, and nursing facility care; durable medical equipment and pharmacy, plus oral health benefits.

Creates a quasi-governmental entity that is exempt from TABOR called Health Insurance Partnership. Also creates and funds the Community of Caring Collaborative Board and the Safety Net Stabilization Program. It will establish comprehensive benefits package, competitively negotiate contracts with private health plans; implement quality standards for insurers and providers; and collect taxes from individuals and employers for the program, and collect monies from state agencies and premiums from health insurers for more funding. It says it will provide a variety of products that modify cost sharing or offer enhanced benefits.

#10 – Healthy Colorado Now – proposed by the Colorado Coalition for the Medically Underserved. Employer Mandated on pay or play basis, which means that employers must pay for insurance or pay an assessment per employee to the state. Policies are guaranteed issue, community rated, standard benefits. There will be a default enrollment system with individual mandates, but the employer is ultimately responsible if the individual doesn't purchase insurance. Benefits will exclude services without proven benefits or with poor cost benefit ratios, so no experimentation or new technologies can be tested or tried. There will be spending caps per individual beneficiary. There will also be a limitation of expensive and heroic services.

Creates the Personal Responsibility Option in Colorado (PRO-CO). Governed by non-profit, non-governmental authority called the Colorado Health Authority. Adopt "medical home" standards, which mandates that every individual must choose a primary care physican who then becomes a gate keeper for specialty services. The plan supposedly creates incentives for standardized care. It will implement new information technology, define standard policy benefits, and provide quality and performance standards. Every non-ERISA insurer must offer at least the PRO-CO benefit package. Individuals do have the option to buy higher levels of coverage. Evidence based medicine.

#9 – An Individual Based Insurance System proposed by the South Denver Metro Chamber of Commerce. Individual and Insurance Company mandates. Mandatory maintenance routine care policies (up to $100,000) and mandatory preventive care (required to get annual exam). Guaranteed issue, community rating. Catastrophic care funded by 5 to 20% of maintenance policy premiums – with financial backing of the pool from a state governmental safety net similar to the role of the FDIC. Mandated benefits on maintenance policies – may limit benefits on cosmetic, self-inflicted, treatment without a reasonable scientific basis, highly experimental, infertility and repetitive injuries caused by extreme choices.

Creates Colorado Health Commission to investigate quality and cost factors that "drive" cost and quality. Discounts for health lifestyle choices. Massachusetts style connector to link insurers and consumers. Vouchers for poor. State clinics for poor and uninsured – one per county.

#7 – Connecting Care and Health for Colorado proposed by CCHI. Universal coverage. Individual and employer mandates. Guaranteed Issue and Community rating. Expansion of public programs. Standardized benefits, including minimum benefit requirement. Diagnosis and treatment, preventive dental care, vision and hearing services, mental health, substance abuse, cancer screenings and other chronic disease screenings, rehab services, non-emergent medical transportation and other appropriate services.

Creates the Stakeholder Oversight Commission to supervise 3 advisory committees – health care quality, rural health and health disparities. Private insurance includes all state mandated benefits and two or three enhanced plans that include vision and dental benefits. Tax assessment on employers with tax credit for those who provide health insurance. Mandate all residents to purchase insurance.

#6 – A Phased Approach to Achieving Universal Health Coverage in Colorado proposed by Kaiser Permanente.
Expand Medicaid programs to children with premium assistance. Individual mandates such that an individual must have coverage through their employer, individually private coverage or through a public program. There will be a tax and surcharge on those who remain uninsured. Guaranteed issue, community rating. Would increase and encourage the use of HMOs. A medical home or primary physician essential. Evidence based guidelines. Statewide medical records database.

Uses voluntary HMOs and providers; but also a statewide managed indemnity plan mandated for those not in HMO. Individuals in indemnity plan must choose primary care physician – a medical home. Reimbursement rate is 100% of medicare for non-HMO providers, HMO rates are reimbursed on a capitated basis and determined at the state level. Individuals eligible for group plan must use that plan. Basic or comprehensive plan with a deductible (0, $2000 or $10,000).

#4 – Comprehensive Health Care Plan for Colorado proposed by CLUB 20. Individual mandates for tier 1 coverage – basic benefits using appropriate associated reimbursement rates using Oregon as model. Providers mandated to participate in quality improvement efforts and meet quality standards.

It would create Colorado Health Commission to coordinate and direct new overarching elements of health care reform. Also would create the Colorado Care Connector to assume role of current medical and efficiently provide Tier 1 coverage to those who can’t afford it. Promote concept of medical home with primary care provider. Can purchase Tier 2 coverage – which allows for unlimited health care options.

#2 – Better Health Care for Colorado proposed by Service Employees International Union. This plan is a bit vague but seeks to create a path for universal health coverage. It doesn't appear to have mandates, but I'm not sure how universal coverage is to be enforced without mandates.

It would create a new quasi-public entity to provide access to private insurance specifically tailored for "target" populations. The exchange would coordinate health care financing from multiple sources, and offer products to subsidized uninsured and non-subsidized small businesses. Would offer limited health plan of $25,000 to $35,000 annual benefit; pre-paid plan; more comprehensive coverage such as in the State Employee Health Insurance Plan, and other plans for indigent or high risks. Managed care approach. Would have employer-sponsored insurance with an opt-out provision.