The health care reform debate was anything but dull. Full of political maneuverings, hyperbolic rhetoric, good intentions, misguided policy, misplaced passion, serious concerns and a complex issue and played out across three 24-hour news stations, it’s hard to think of anything more dramatic and engrossing this side of Mad Men.
Until now, that is. Because now the real decisions are being made, the ones that will impact every employer, every carrier, every broker and every American in very direct ways. This is where the nitty gets gritty, the proverbial rubber is introduced to the road, and … well, jump right in with your own metaphor.
They say the legislative process is akin to the making of sausage. But when it comes to unpalatable activities, the implementation can be just as bad – if not worse. And it’s causing sleepless nights for employers, brokers, individuals and insurance executives.
Not that anyone should feel sorry for them, but just for fun, let’s walk a few steps in the shoes of those health insurance company executives. They have a lot of moving pieces to deal with. Consider, as of September 23rd: lifetime benefit caps go away; rescissions are greatly restricted; pre-existing conditions – for children under age 19 they are a thing of the past; specified preventive care services are paid at 100% – no cost sharing allowed; limits are imposed on out-of-network emergency room services; dependents up to age 26 must be covered (but not those dependent’s dependents); new criteria of acceptable appeals processes (for denied claims or treatment) take effect; and new rules concerning non-discrimination in favor of highly compensated individuals come into play.
And this list just describes the impact of the new health care reform bill. States are imposing new rules and regulations at the same time. And let’s not forget the federal mental health parity legislation that took effect July 1, 2010. Then, looming just down the road, there’s the new medical loss ratio requirement (which mandates carriers spend 80 percent of the individual or small group health care insurance premium they take in on medical claims and health quality initiatives beginning January 1, 2011 – 85 percent of large group premium must be spent on these purposes).
Now think about the answers those health insurance executives have to come up with. What specifically to these new rules require? Details on some are sketchy at best. And regulations, like legislation, is open to interpretation. How will state regulators interpret what these federal rules require? How will competitors implement them? Can our systems handle the new calculations, structures and rules without exploding? How do we explain how we’re interpreting the requirements to our customers, brokers and front-line employees? All this while the fallen economy and skyrocketing medical costs buffet their companies like Dorothy’s tornado.
Again, no need to feel sorry for them. This is, after all, what they signed up for. But it is fascinating to consider the complexity of their task. And to make their task all the more exciting, any missteps could put their company – and themselves – on the front page of their local newspaper. And trust me, that’s not where any executive wants to be for anything other than handing over a big check to the United Way.
Then there’s the reality that every decision matters. And with every decision the safety net gets smaller. When Congress passes a law, they have regulators as their safety net. Which is why most every major new law delegates a great deal of responsibilities to federal and state agencies. Those agencies , meanwhile, know that those they regulate will find a way to smooth the edges of the regulations they develop. But carriers – and employers, brokers and others who have to actually implement all this – have no safety net, no one accepting the buck they wish to pass. Lawmakers and regulators deal with what should happen. Employers, brokers, and carriers do things. They deal with what will happen. And if they’re wrong (meaning the regulators or lawmakers upstream think what they did is wrong) the consequences can be dire.
Which is all to say the summer hiatus is over. What I’ll try to bring to you in the weeks ahead is to provide readers with the information needed to track what’s happening now with health care reform, how it’s being interpreted by regulators and how it’s being implemented by health plans, employers, individuals and others. My goal is to provide links to the reports, resources, and articles you need to stay current. And I’ll do my best to provide additional insight and context to what’s happening, to the extent that’s possible.
Given the complexity of what’s involved with implementing health care reform, your help will is greatly needed. For example, a lot of the action takes place at the state level. Please feel free to leave comments with reports about what you’re seeing happening in your neck of the woods, wherever that may be.
There’s a lot happening and a lot to talk about. I hope you’ll be part of the conversation, because here we go. Again.