One of the reasons I wanted to return to journalism after a long career as an insurance company PR man was to keep an eye on the implementation of the new health reform law. Many journalists who covered the reform debate have moved on, and some consider the writing of regulations to implement the legislation boring and of little interest to the public.
But insurance company lobbyists know the media are not paying much attention. And so they are able to influence what the regulations actually look like--and how the law will be enforced--with little awareness, much less scrutiny.
At a January meeting of several hundred patient and consumer advocates in Washington, a top aide to Health and Human Services Secretary Kathleen Sebelius all but pleaded with those in the audience to bombard the Obama Administration with messages insisting that the law be implemented as Congress intended. Rest assured, he told them, that the insurance industry's lobbyists were relentless in their demands that the regulations be written to give them the maximum slack.
One example: a section of the law expanding the rights of consumers to appeal adverse decisions made by their health plans.
"The Affordable Care Act will help support and protect consumers and end some of the worst insurance company abuses," read an Obama administration fact sheet from last summer.
The fact sheet went on to assure us that the new rules would guarantee consumer access to both internal and external appeals processes "that are clearly defined, impartial, and designed to ensure that, when health care is needed and covered, consumers get it."
"In implementing this law, we have worked to end the worst insurance company abuses, preserve existing options and slow premium increases," an administration official said. "Through it all, protecting consumers has been -- and remains -- our top priority."
The rules, originally scheduled to go into effect July 1, 2011, were actually written by the National Association of [State] Insurance Commissioners (NAIC), which was tasked by Congress to develop several important regulations required by the law. If the law is implemented as the NAIC recommends, patients will be able to get an external appeal of a broad range of coverage denials, including denials that result from an insurer's decision to rescind, or cancel, a patient's policy--not just denials made on the basis of "medical necessity" as determined by the insurer.
The NAIC's standards also say that insurers must provide consumers with clear information about their rights to both internal and external appeals and that the companies must expedite the appeals process in urgent or emergency situations.
Well, surprise, insurers don't like being told what to do by regulators. So they're pushing back hard. Consumer advocates who have been in meetings at the White House in recent weeks say they believe the administration is bending over backward to accommodate the insurers.
"We have reason to fear that the external appeal regs won't be very consumer friendly," said Stephen Finan, senior director of policy for the American Cancer Society Action Network.
Finan and representatives of several other consumer and patient rights organizations, including Consumers Union, the National Partnership for Women and Families and the American Diabetes Association, wrote officials in the Departments of Labor and Health and Human Services in late January pleading with them to "stand firm for consumers" in rejecting several of the insurance industry's demands.
They expressed concern that the final regulations would allow insurers to stack the decks against patients by allowing health plans to deem a second-level internal appeal of a denial as meeting the requirement for an independent external appeal. They're also worried that health plans will not be required to provide clear and understandable information to policyholders about their denial decisions, that the plans will not provide adequate translation of written communications into other languages (insurers are claiming this would be too burdensome), and that they will be able to take as long as 72 hours (instead of the recommended 24) to decide an urgent appeal.
Equally as frustrating for the consumer advocates is the administration's indication that they will give the insurers until January 1, 2012, rather than July 1, 2011, to comply with the regulations.
Consumer advocates say the administration has told them that the reason it is proposing to delay the effective date of the new rules for half a year is to accommodate the health plans' enrollment cycles and marketing needs. Health plans do need adequate lead time to make changes to their systems and to prepare materials to inform their customers of new procedures, especially in multiple languages, so some of their push back is understandable. The new regulations will also add to the insurers' administrative costs, and the new law limits how much they can spend on overhead.
But the consumer groups believe the administration itself has caused some of the problems by taking so long to finalize the regulations. The NAIC got its work done comparatively swiftly.
"There is a clear pattern of leaning toward the insurance industry more than consumers," one of the patient advocates told me.
The consumer advocates, most of whom not so long ago were applauding the Democrats for getting reform enacted, even if it fell short of their original goals, are becoming increasingly discouraged, partly because there are so many more lobbyists for the insurers than for consumers. It's hard to compete with them.
"We're outnumbered 100 to 1," said one of the consumer advocates.
It's clear," he added, "that the insurers are willing to make life more difficult for patients" by trying to weaken and delay the consumer protections.
It's also clear that, at least for now, the insurers seem to have the upper hand in dealing with the White House.
Follow Wendell Potter on Twitter: www.twitter.com/wendellpotter
This very flawed and inherently corrupt system is why America's governmental policies and laws are so biased in favor of industry and against the best interests of it's citizens. One big reason for this is the mistaken, knee jerk belief that enacting regulations or laws that protect citizens is somehow anti-business. Both the business and political communities, along with far too many naive consumers, need to let go of this destructive belief. Protecting consumer/citizen rights by reigning in the ability of businesses to behave badly and irresponsibly, and to hold them accountable in a meaningful way, is NOT anti-business. People who think it is are exactly those who need to be regulated because they are incapable of doing so themselves. They are the business people who poisen the well for honest businessmen as well as consumers,
The individual mandate is going to happen whether you progressives and teabaggers like it or not. Sure, the individual mandate isn't perfect, but perfect is the enemy of the good. Some people will still get subsidies to buy private health insurance. Half a pie is better than no pie. THERE JUST AREN'T ENOUGH VOTES IN CONGRESS FOR ANYTHING BETTER!
Besides, the public option is completely unnecessary. The exchanges will take care of EVERYTHING!
You progressives have to realize that you are a tiny minority in this country. The sooner you realize it and completely support the democratic party, the better for all of us. President Obama is the best you're ever going to get. Better start being grateful to them for his hard work.
Obama is playing a very delicate game of chess with the Republicans. All the progressive dissent is very disturbing to Obama and his real supporters. But it IS music to the Republicans' ears!
And cheer up -- soon, ALL 50 million + of the irresponsible fools out there without health insurance who are clogging up our ERs will be forced to buy health insurance. And if they don't, they'll pay a fine. I hope all the stubborn, selfish holdouts lose
Health care insurance should be for catastrophic events. It should be like car insurance. It covers you (and your victim) in the event of an accident. But it does NOT pay for routine stuff like oil changes. And, if auto insurance covered gas, it would be 80 dollars a gallon, and then the people without it would be really screwed. That's where we are right now with health care. The industry has created a need for the services they provide by leeching onto the doctor-patient relationship, while contributing NOTHING to health care itself. Time to dig this industry out of all the cracks and crevices where they don't belong, and return health care to the marketplace and let the system work as it should.
That’s why Medicare was invented.
The reason millions lose coverage each year: Insurers want healthy clients. throw the sick ones out. They create thousands of pools, big an small. small pools are crazy expensive .Individuals cant handle the high rates thats why they work for organizations with large health insurance groups. Thats why we need 2 tiered Health Care 1st level single payer covers everyone second level would be the secondary market option that Conservatives/Republicans/Libertarian/Free market zealots can do their own thing. No opt out. Pay for universal coverage the same way we pay for Fire/police protection. If you want a sprinkler system and alarms added security go ahead but your not gonna avoid paying for the basics. Health Care is not the same as other retail purchases.
When insurance companies spend big money on advertising on networks/websites/radio stations that broadcast "news", I don't expect the media to bite the hand that feeds. The media is being paid not to pay attention.
The same would apply to any industry that spends money on advertising. Hence the problem with corporate media.
I haven't seen BP in the news a lot, either. All I see is a bunch of BP ads telling everyone about how great they are at cleaning up their mess. BP is spending a lot of money to make everyone forget.
By that standard, we spend about one trillion dollars more, every year, than necessary.
Several factors play into that degree of waste, and, insurance companies play a big part. Mr Potter is absolutely correct. There are hundreds of billion at stake here....and that amount of money will guarantee an army of lobbyists at work to keep the American "pay for play" system of government functioning in support of the insurance companies.
As for the rest of us.......we lose.
That's Amerika.
The Rich are the masters and we are the dogs.
That's why health care "reform" is such a joke, which makes it exactly like every other "reform" that corporations pretend to be so aghast about publicly but privately move along by writing the legislation.
The saddest aspect is that there are people out there who actually believe the healthcare corporations and insurance corporations are against the Health Care Reform Act because that spend a few dollars to take out ads to make a public showing of their "opposition" to the legislation that their lobbyists are presenting to "our" legislators to vote for.
This is VERY important. Please keep informing us on this issue.
Many of us have feared that the Obama health care reform bill...
Better known to many of us as the Giant Giveaway To The Health Insurance Industry Bill... would be corrupted during the rules making process.
This is not looking good.
In House bill 115 there is an attempt to pack the advisory board tasked with creating healthcare insurance exchanges with Blue Cross/Blue Shield reps and lobbyists.
BC/BS of course has a near monopoly in NC.
Call you representatives and tell them, NO! You want a variety of choices in healthcare insurers as well as plans, to 'insure' competition and keep prices lower.