Health Reform When your Life Depends on it: Seven Essential Principles from the Multiple Sclerosis Society

Multiple sclerosis is a challenging illness that raises difficult issues in every area from basic stem cell research to insurance reforms, to disability policy, to clinical research and care. Not surprisingly, then, the MS community is anxiously watching the health reform debate.

A friend recently sent me the National Multiple Sclerosis Society's National Health Care Reform Principles. If you haven't seen their report, you should. NMSS enunciates seven basic principles that provide a great starting point to evaluate the two candidate's competing plans. I've culled bits and pieces from this short document. It reflects the unique perspective of people whose lives, health, and financial solvency are deeply affected by what will happen on November 4.

Let's start with Principle #1. Accessible health care coverage:

Access to appropriate public or private health coverage should be assured regardless of health or disability, employment status, age, claims history or risk. • Coverage should be guaranteed renewable and portable. Waiting periods, pre-existing condition exclusion periods and other measures designed to prevent consumers from participating in insurance should be eliminated... (Achieving full population coverage would reduce the need for these.) [That's their comment in the parenthesis.]

That's a pretty good description of the insurance market operated in accordance with the Obama plan. It is the precise opposite of what Senator McCain proposes. The McCain plan allows and encourages medical underwriting by loosening state regulations that now protection people with chronic illnesses.

More important, by taxing employer-based health coverage, the McCain plan seeks to shift millions of Americans into the nongroup health insurance market where medical underwriting is standard practice. Surveys indicate that two-thirds MS patients are privately insured, typically through their own or their spouse's employer.

The situation isn't great. Controlling for age, income, and other factors, privately-insured patients are more likely than people with public insurance to report difficulties paying for health care, to skimp on medications, and to spend less on food, heat, and other necessities to pay their medical bills. Still, people are substantially protected against being charged the full "actuarially fair" premium associated with MS care. The McCain plan places that arrangement at-risk. It would give a single adult a $2500 insurance tax credit. In 2004, the average annual medical expense of MS care was almost $13,000.

Shamed by Elizabeth Edwards, who noted that neither she nor Senator McCain would be covered by his health plan, Senator McCain says that he would "work with the states" to support Guaranteed Access Plans. Teh campaign provides no details, and the $7-10 billion it proposes to allocate wouldn't come close to meeting the need. Given the poor track record of state high-risk-pools created for the same purpose, people with chronic illnesses are justifiably wary.

Here is Principle #2: Affordable health care services and coverage:

People with chronic illness or disability are especially likely to be underinsured. That includes people with high deductible health plans, Medicare beneficiaries who cannot afford the Part D "donut hole" or a supplemental policy, and those who must pay 25% or more in co-insurance for essential drugs.... Insurance premiums become more affordable when based on the broad dissemination of risk through community rating and re-insurance methods, and sliding scales to help those at lower incomes.

The Obama plan includes community rating, reinsurance, and heavy support for low-income consumers. The McCain plan assigns high-deductible health plans a central place. As I have written before, such plans are highly inappropriate for low-income consumers. These plans are widely feared among people with chronic illnesses.

Principle #3: Standards for coverage of specific treatments should reflect reasonable prospects for improvement and/or prevention of deterioration.

Well-designed studies produce the scientific evidence necessary to continuously improve our understanding and promotion of quality MS care. Yet, when health plans condition coverage or reimbursement on overly strict standards of evidence, people with chronic and degenerative conditions are denied access to needed care.

This is a complicated subject, because payers sometimes have to say "no." Whom would you trust to make these tough calls: a state regulator-shopping insurer, or one overseen by the national insurance exchange of the Obama plan which also provides the backup option of joining a public plan.

Principle #4: Elimination of disparities in care

This one answers itself.

Principle #5: Comprehensive, quality health care available to all

Health care services for individuals with chronic illnesses should include access to the full spectrum of health care needed throughout the person's life. Any coverage plan should include a set of comprehensive benefits to address the most common areas affecting people with chronic conditions, including but not limited to: medical care, prescription drugs, dental care, rehabilitation services, preventive care, hospital in-patient care, mental health, durable medical equipment and hospice care.

This comprehensive vision is the antithesis of the current offerings on the nongroup market, let alone what is offered through high-deductible plans. Nongroup plans are much less likely to cover preventive, dental, mental health services. They impose high deductibles and copayments on most other items on that list. Many studies indicate that people are less likely to use preventive services under such plans. The McCain plan, by facilitating sale of policies across state lines, would weaken state regulations that require coverage of cancer screening, mental health services. and a host of other important forms of care. The Obama plan, in contrast, would anchor health insurance based on what is currently offered to federal employees.

Principle #6: Increased value of health care

The value of health care should be increased through the universal use of interoperable electronic medical records and increased emphasis on prevention.

I'm not expert here. I will simply note that Senator Obama proposes up-front investments in medical IT and other efforts to achieve this vision. He also proposes investments in public health infrastructure to complement clinical preventive services.

Principle #7: Access to high-quality, long-term supports and services.

Any health care reform that does not address the need to improve the provision of long-term care in America creates a false dichotomy between health care and long-term care. People living with chronic, disabling conditions understand fully that access to quality long-term supports and services is integral to maintaining optimal health.

As I have noted, long-term care hasn't gotten the attention it deserves. Democrats have spent the last seven years fighting Bush administration efforts to cut Medicaid payments of critical interest to the disabled. HHS Secretary Michael Leavitt told a conference of healthcare executives: "Medicaid must not become an inheritance protection plan." Leavitt's pretty moderate. So I think this comment is especially telling. The party that rails against the "death tax" imposed on a tiny group of multi-millionaires is oddly sanguine about the fact that many of our friends, neighbors, and loved ones will contract multiple sclerosis, heart failure, dementia, or some other chronic diseases, and then risk losing a lifetime of savings over a few months of skilled nursing care.

You get the picture. In just about every particular, the Obama health plan provides a great advance over the current situation. People living with MS need serious help. Most are insured, have worked for decades, and are now treated shabbily by our health financing system. Others with equally serious diseases are treated similarly. Senator McCain's plan would not address their concerns. Instead, it would make a difficult situation even worse. If you, or someone you care about, might someday face a serious chronic illness--and that's pretty much all of us--you have four weeks to make a difference.

One more thing. If you live in the DC area or are simply jazzed about disability issues, you might want to attend a neat event hosted by Americans with Disabilities, Families, Friends and Advocates. It is called "breaking down barriers and creating equality and justice for all," and it benefits the Obama Victory Fund.

Some cool people will be there, including House Majority Leader Steny H. Hoyer, Congressman Edward J. Markey, and Congressman Keith Ellison. If you want to come, click on the URL. Make sure to note that I am the person who encouraged you to come.

Comments

[DarkShark]

These points are very strong and will give a strong foundation for a better health care system.

[DarkShark]

Great analysis. I think these principles that you've shared are a strong foundation for moving forward toward meaninful change. I find is troubling that more light has not been shown on McCain's frightening health care proposals! They might work as long as you don't get sick or need any health care but if you do get sick - look out... More of the public needs to analyze the two plans. For instance, McCain will actually tax helath care benefits from your employer! That has never been done. This is McCain's plan to move away from employer based care. Well, I like me employer based care. I like Obama's approach of letting folks keep what they have and then work on helping the others. Thanks for focusing on this!

[QualityCounts]

It's heartbreaking but nice to remember that economic theory and political posturing eventually translates into real medical care for real people with real diseases. Sometimes we get so involved with academic arguments and political debates that we forget that vulnerable people are dependent upon who gets elected. GO OBAMA 08

[ThomH]

Obama's health plan is a shameful buckling under to the health insurance lobby.

He once supported single payer health insurance, now does not.

Why?

His stated reason "because we already have something else" makes no sense whatever. By that logic, we would still have slavery, male-only suffrage and Jim Crow.

Joe Biden offered the simple, honest reason why he does not favor single payer: "I don't want to be eaten alive by Harry and Louise"; i.e., the health insirance lobby.

In short, even though majorities of both voters and physicians favor single payer, both Obama and Biden have been brought to heel by the financial clout of the healthcos.

Keeping healthcos in the act wastes $1 billion per day; over ten years, $10,000 for every person in the US.

Obama's shameful plan will only make this drain on the economy worse: at least $3 trillion will go down the drain over the ten years it has been estimated it will take the electorate to wake up and demand single payer.

[ConcernedMD]

I agree. From a policy standpoint, these are the right issues and they're very poorly addressed in the McCain plan. While no plan is perfect, at least Obama is tackling these tough issues.

[AllAboutHealthPolicy]

I would like to expand on Principles #3 & #6. How we make decisions on coverage and the concept of purchasing value go hand in hand. We should be making coverage decisions with respect to each benefit's relative value. California, 6 years ago, embarked on a remarkable process for deciding which benefits are mandated for coverage in all health plans. Prior to instituting this process, there were no criteria nor process in place for any rational consideration or thoughtful deliberation -- nearly all coverage decisions were based on politics and were easy wins for legislators. They could satisfy their constituents at no cost to the state budget because the private health plans and purchasers would pick up the tab.

In California, before any new health insurance benefit can be considered by the legislature, it must go through a rigorous review of the evidence on its medical efficacy and effectiveness (conducted at UCSF. The impact of the costs i(conducted at UCLA. And its impact on the PUBLIC"S HEALTH (conducted at UC Berkeley). Reports are due 60 days from a bill's introduction and NO hearings can be held until the report is completed

Value mean thats we "purchase health improvement at a reasonable cost for those treatments that have been demonstrated to be effective."

If we did this at a national level, the health care system would work better at every level and people would get real value for their health care dollars.

[Wantowin]

Pollack has it right. No matter how you look at it, the Obama plan is superior to the McCain plan. As summarized by an excellent article by Collins and colleagues today in the Commonwealth Fund publication (The 2008 Presidential Candidates' Health Reform Proposals: Choices For America), the Obama plan is designed to ultimately cover everyone, to provide a standard benefit floor, to make insurance affordable relative to income and to improve quality and efficiency. The McCain plan will accomplish none of these. Lots of people who currently have insurance through their jobs are going to be losing those jobs over the next years, because nothing that anyone does is going to turn the economy around in a very short term and unemplyment is going to rise. All of those people are going to swell the ranks of the medically uninsured unless something is done quickly to fix our broken system, and only Obama is likely to get that done.

[vivisel]

great post. let's make this an issue!

[TopProf]

Pollack's post should be forwarded to everyone you know. It's not just about MS patients. I will retire soon and leave my insurance plan behind. Because I have a chronic disease, I will not be able to get insurance on the private market, under the McCain plan. My home will be at risk and even after working for forty years I must seek a second career.
His plan is completely under the sway of the big insurance corporations whose whole business plan is to deny claims and exclude sick people.
Please vote for Obama. His plan isn't perfect, but it will keep me and millions of others off the dole.

[Student Dr]

I think that TopProf's point is a very important one:

Chronic Illness is not an issue that is unique to the MS community. As a recent college graduate, a new medical student and someone with a chronic disease, I had to be very careful about making sure that I was adequately insured in the interim between schools, because a gap in coverage might have been considered grounds for refusing new medical insurance or a substantial increase in my premiums. This is because chronic illness falls under the umbrella of these "pre-existing conditions" that insurance companies use to stratify their risk at the peril of their clients.

Another important point to make is that Chronic Diseases are enormous source of profit motive and innovation within our present healthcare system. The market for drugs for chronic pain management, arthritis, hypertension, cholesterol management DWARF THE MARKETS for antibiotics and chemotherapeutics. Every pharmaceutical company in the world is dependent on chronic disease for solvency.

The chronically ill are the best customers in the healthcare industry, shouldn't we treat them as such? The need for more cost-efficient management strategies is clear but, in the meantime, the healthcare industry needs the chronically ill as much as the chronically ill need healthcare.

[kirkmc]

For the most part, you're describing France. I live there, and have for 24 years after spending the first 25 in New York City. With a chronic disease myself, I can relate to everything said in this article. Needless to say, the main reason I don't move back to the US is health care.