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Congressional Delegate Donna Christensen and the House Health Care Bill

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Delegate Donna Christen-Christensen (D-U.S.V.I.) is a member of the 111th Congress, serving her seventh term. Christensen is the first female physician in the history of the United States Congress, the first woman to represent an offshore Territory, and the first woman Delegate from the United States Virgin Islands.

She serves as an assistant Majority Whip and is the chairwoman of the Congressional Black Caucus' Health Brain Trust.

We talked extensively about the House health care bill that passed by a vote of 220-215 on November 7th.

Kathleen Wells: As a physician, what do you see as the advantages and disadvantages of the House health care bill?

Delegate Donna Christensen: What are the disadvantages of the bill? It is a major expenditure at a time when we have a huge deficit. I really can't think of much else that is negative about the bill except that I think we could have done more in some areas, but because of cost concerns, we were not able.

The benefits of the bill, some of which begin right away, are some of the insurance reforms. Now, we don't get quite as far as the bill will take us for ending exclusions for pre-existing diseases [right now], but we do make some steps to curtail that exclusion and we do also provide a national risk pool of insurance for those who are not able to get insurance between now and 2013.

So, we do a lot to make sure that some of those insurance reforms take place [now], for instance, no rescissions and we also have some provisions that will limit how much insurance companies can increase premiums as we saw the credit card companies do before.

But getting to 2013, I think the basic benefit package that will be developed and the exchange where people will have a choice of getting into a public plan as we hoped or private insurance plans that have to abide by federal regulations, provides a great opportunity for people who are not insured to now be insured.

We anticipate that we can insure up to 36 million of the 46 million who are uninsured, unlike the Republican plan, which would only insure three million more.

[Here is] the help that families will get: First of all, the increase in Medicaid to cover up to 133 percent to 150 percent of the federal poverty level and who meet the guidelines, who may not be disabled but who may be young, but unemployed, is something new and will help a lot of young people who cannot be insured right now. Also, young people up to age 27 will be able to be covered on their parents' policy.

There are health subsidies in the exchange for those [earning] up to 400 percent of poverty level and we cap what a person should have to pay as a percent of income.

There will be transparency on how insurance companies set their premiums and change their premiums. And of course, there's the 85 percent medical loss ratio that we are imposing on the insurance companies. This ratio means that 85 percent of premiums must go to cover medical services.

[As chairwoman of the Congressional Black Caucus' Health Brain Trust] and [as] a member of the Tri Caucus, I know we worked very hard to include provisions that we feel our communities, rural communities and [the United States] Territories need, because we have not been able to be in the health care mainstream, so to speak.

Work force expansion is a very important part of the bill as a whole. Within that, we have provisions that would increase the diversity of the workforce so that we have more people that speak different languages [and], who come from the same cultural, racial and ethnic background as the patient. Studies have shown that when [the patient and the health care provider have the same or similar cultural, racial and/or ethnic background], there is more trust and out of that trust, there is more understanding and out of that trust and understanding comes more compliance and better outcomes.

[Also, for] the very first time, we are beginning to change the paradigm from all acute care to really bringing some focus to prevention.

What the bill does is make insurance more affordable for those who can't now get it and keeps the cost of insurance down for those who do have it.

I can't really think of too much negative in it.

Kathleen Wells: Why is there a four-year delay in implementing the provisions of the bill?

Delegate Christensen: The time it takes to set it up, the time it takes to have a public exchange Commissioner. We have to develop the public plan and we have to put the infrastructure in place.

There is a lot of work to be done after we pass this bill to get to implementation and that's going to take a couple of years. And we want to make sure when it is in place we are doing it right.

Kathleen Wells: Critics say the House bill doesn't contain a strong enough public option because instead of operating like Medicare, it negotiates payment rates with health care providers just like private insurance companies. Do you agree with this assessment?

Delegate Christensen: I don't. And I've been trying to tell our leadership that they should stop calling it negotiated rates because it isn't a true negotiation. It is based to some extent, on Medicare rates in that the Secretary [of Health and Human Services] will be authorized to set a reimbursement rate somewhere between the average Medicare reimbursement and the average private insurance reimbursement in a particular region. It could be Medicare plus 5 [percent] or plus 7 [percent] or 10 percent. But it is somewhere in between. It would be below what the private insurance plans are paying, but above the average Medicare rate.

The Secretary will not be sitting down with each hospital and each provider group to determine what the payment will be; and because we aren't trying to make a profit, the cost of running the plan will be less and the cost of premiums and co-pays will be much more affordable in the public plan.

Kathleen Wells: What do you say to critics who are concerned that too few people will have access to the public option?

Delegate Christensen: We are trying to not disrupt the private insurance market, so we allow those people [who are already insured] to stay insured, so they would not be able to access it [the public option] - at least not at this point in time. Maybe [they would be able to do so] at a time in which their companies decide to change their insurance in the normal course of business. But they would not be eligible unless the insurance premiums become above the 12 percent of their income. [If that happened,] then they would be able to come out and go into the exchange.

With small businesses, they will be exempt if their revenue is 500 thousand a year or less and their employees will be able to access the exchange.

For businesses with a revenue of more than 500 thousand a year and for corporations, gradually, not in the first, but maybe the second or third year, they will be able to access the exchange.

Kathleen Wells: What is your position on the individual mandates contained in the bill?

Delegate Christensen: I think there has to be a mandate. I think that everyone needs to be included or we miss the mark on this. There should be something that incentivizes [sic] or pushes people into being insured. That's how we bring down the cost -- you have a wider risk pool.

People talk about young people may not want to be insured. They ought to be insured. They never know what's going to happen. You will bring down the cost of insurance for them over the long term and for all of us.

I believe in the individual mandate.

Kathleen Wells: I read on your website that you and some other members of various caucuses have met with the President. Is there anything you'd like to share about that meeting?

Delegate Christensen: It was the Hispanic, Black, Asian-Pacific Islander Caucuses and the Progressive Caucus. The three minority caucuses came together and formed some basic provisions around health care reform. The Progressive Caucus joined with us on many of the provisions.

Some of those provisions we were able to get in the bill. Next we have to look to the conference committee to try and see that those provisions that are important to us stay in. For instance: the language provision, for those who have limited access to English proficiency; data collection provisions; the community health centers; community health workers, i.e., increasing the diversity of the workforce. Those kinds of provisions, we want to make sure that they stay in.

We went to the President to say we've been able to get these things in the bill; [but] they are not in the Senate bill and we are asking you to weigh in on our behalf regarding health equity or health disparity eliminations provisions as we go through conference. These provisions are very important in making sure that everyone is provided with better health care.

At that time [before the bill passed,] we were working on trying to ensure that children had a full range of wrap-around services, whether they are in Medicaid, SCHIP or in the exchange. And we were also working at that time to codify the Office of Minority Health, to give it more permanent standing and authority within the Department of Health and Human Services. So, we were still working on those two issues and we asked [the President] for some help on those two issues.

There is still an issue outstanding about whether people should be required to have proof of citizenship in the exchange and, of course, we support the Hispanic and the Asian-Pacific Caucus on that [issue.]

The President discussed all of these issues with us. Some of them the President supported, he questioned others and others he took under advisement.

Kathleen Wells: What is the position of the Black Caucus' Health Brain Trust (which you chair)?

Delegate Christensen: Our position is reflected in another bill, HR 3090, which is the health equity bill, which we have introduced in the last four congresses. It's a Tri-Caucus bill, which addresses all of the things that we wanted to see in the bill - much of which we did get.

Kathleen Wells: A generation from now, how do you think American citizens and historians will view this bill?

Delegate Christensen: As historic. They are going to say that the people who crafted this bill and stood by it and pushed it through made a dramatic change in the lives of people who live in this country. Not only will we be healthier, we will be more productive. That means our country will be stronger [and] more competitive. When this happens, it will essentially begin to change the economy. In terms of the savings, it will bend the cost curve.

Right now, we are 37th in health status in the world and 40th or 41st in infant mortality. Our health indicators in comparison to even some developing countries are not good. But that will change with this if we do the full bill and do it so that everyone has access to insurance and we provide some of those services that close the gap that some people are experiencing in health services and health status.

Kathleen Wells: Is there anything else you'd like to address?

Delegate Christensen: Just to say that I represent a [United States] territory and while we didn't get full parity with the states in Medicaid and in the exchange, we did [get] significant increases in Medicaid for the territories and we are included in the exchange. It is my position that the Territories must receive equitable treatment; however, this is a first step for us. I think the bill needs to be seen as a very important step, but just a first step in all that we have to do to really reform the health care system in the country.

This piece is cross posted from the Philadelphia Tribune.