Fear of absorbing health insurance costs hit San Diego’s youth

Health care reform remains a hotly debated issue. It makes sense. The U.S. Census Bureau reported 46.3 million people had no health insurance in 2008.

Still, the debate has failed to highlight a key group: young people even though the health care package will affect them just as much. The issue is more so prominent in college town, San Diego.

In 2008, people age 18 to 24 had the highest rate of no health coverage at 28.6 percent, according to data compiled by the U.S. Census Bureau. The second highest uninsured group included people 25 to 34 years old at 26.5 percent. Thus, young people constitute more than half of all uninsured people in the U.S., according to the report.

If the proposed health care reform is passed, college students would be greatly impacted and in multiple ways.

First off, the millions of people who are uninsured, which includes college students, would have to obtain insurance, said San Diego State University political science professor Brian Adams.

In fact, he said this is one of the positive aspects of the legislation.

“Young people should probably get insurance anyway, because even if you’re healthy you can get into a car accident or you can have some catastrophic illness,” he said. “If you get into a car accident and you have $200,000 of health care debt, it can bury you for decades.”

SDSU journalism and media studies senior Natalie Scott is thankful to have health insurance through her parents’ plan while she is in school. She is concerned, however, about being covered once she graduates.

“I want to be covered even when I’m done with college and have my first real life job,” she said. “I won’t be getting paid too much so it is important to me that I get coverage and can afford it while I am working on my career.”

Other students, like Mary Zhong, have no health insurance. Her health care was terminated under her parents’ health plan when she recently turned 20. Zhong, who is a political science major, said she is “immensely” concerned about health care and hopes to purchase coverage through her part-time job.

“I recently studied abroad in Oxford University in England and was in awe of their universal health care system,” she said. “The U.S. is a highly industrialized nation, and yet I find it baffling that we are without some form of universal medical access. Everyone needs health care, and it should be easy to access.”

New Rules Promise Better Mental Health Coverage

WASHINGTON — The Obama administration issued new rules on Friday that promise to improve insurance coverage of mental health care for more than 140 million people insured through their jobs.

In general, under the rules, employers and group health plans cannot provide less coverage for mental health care than for the treatment of physical conditions like cancer and heart disease.

Insurers cannot set higher co-payments and deductibles or stricter limits on treatment for mental illness and addiction disorders. Nor can they establish separate deductibles for mental health care and for the treatment of physical illnesses.

Such disparities are common in the insurance industry. By sweeping away such restrictions, doctors said, the rules will make it easier for people to obtain treatment for a wide range of conditions, including depression, autism, schizophrenia, eating disorders and alcohol and drug abuse.

For decades, many health plans have had limits on hospital inpatient days and outpatient visits for mental health treatments, but not for other types of care.

Kathleen Sebelius, the secretary of health and human services, said the rules guaranteed that people with debilitating mental disorders would not suffer “needless or arbitrary limits on their care.”

The rules, which take effect on July 1, carry out a 2008 law that was adopted with bipartisan support. They significantly expand the rights of people with mental illness, much of which goes untreated because of insurance restrictions.

Under the rules, insurers can still review claims for “medical necessity,” can still require prior approval of some services and can still charge consumers more for using doctors and hospitals that are not on a list of preferred providers.

But under the rules, insurers cannot use these techniques in a more restrictive way for mental health care than for other medical services.

The administration said the new requirements could increase premiums by four-tenths of 1 percent, or $25.6 billion over 10 years. Businesses with 50 or fewer employees are exempt.

The rules apply to group health insurance plans of the kind typically offered by employers. Federal health officials said the rules did not apply to the individual insurance market, where policies are sold directly to individuals and families. However, some states have laws that apply to the individual market.

Irvin L. Muszynski, a lawyer at the American Psychiatric Association, praised the government’s decision to require a single deductible for mental health and medical-surgical coverage.

“Patients with mental illness often have general medical conditions like diabetes or high blood pressure that require treatment at the same time,” so a combined deductible makes sense, Mr. Muszynski said.

The rules were developed by the Labor Department, the Department of Health and Human Services and the Internal Revenue Service, which share responsibility for their enforcement.

The government said the rules would benefit 111 million people in 446,400 group health plans offered by private employers, and 29 million people in 20,000 plans sponsored by state and local governments.

In the new rules, the government says a health plan would be violating the law if it “imposes an annual $250 deductible on all medical-surgical benefits and a separate annual $250 deductible on all mental health and substance-use disorder benefits.”

The rules say that an insurer may require “prior approval that a course of treatment is medically necessary.” But the insurer cannot enforce this requirement in different ways for medical benefits and mental health services. For patients who receive treatment without prior approval, the penalty must be the same.

A number of companies specialize in managing mental health benefits. The Obama administration said the techniques used by these companies would hold down the cost of complying with the new rules.

But, it said, the standards and techniques used to manage mental health benefits must be comparable to those for other medical care and cannot be applied more stringently.

In a preamble to the rules, the Obama administration said that patients had typically faced higher co-payments for visiting mental health professionals than for visiting primary care physicians.

The rules are likely to reduce this disparity, so more people will be treated by mental health professionals, the administration said. This, in turn, “could lead to more appropriate care and thus better health outcomes,” it said.

The law requiring parity in the coverage of mental and physical illnesses is named for its sponsors, former Senators Paul Wellstone, Democrat of Minnesota, and Pete V. Domenici, Republican of New Mexico.

What About Health Care Reform?

President Obama mishandled the important topic of health care reform during his State of the Union speech on Wednesday night.

He spent little time discussing the issue, but when he did, he showed no sign of changing his method or learning from his opponents, insisting once again, "Our approach would preserve the right of Americans who have insurance to keep their doctor and their plan." But where is the evidence of this? Both major bills before Congress include clauses which dictate exactly the kind of insurance you can have and what you can't.
And where is the incentive for doctors to keep accepting this insurance? More than 50% of practicing doctors already don't accept Medicaid, according to a 2005 survey, and the Medicare Payment Advisory Commission determined in 2008 that 28% of Medicare patients were unable to find primary care doctors. The yearly doctor dropout rate in private insurance exceeds 10% in many places, including New York.

President Obama went on to state that the health reforms would "reduce costs and premiums for millions of families and businesses," but how so? In Massachusetts, for example, insurance premiums went up when companies were compelled to cover pre-existing conditions and not drop anyone when they were sick. Noble ideals, but costly. And the rate of unnecessary ER admissions has remained steady at 15% even after universal health coverage passed in the bay state. "Patients will be denied the care they need" if health reform doesn't pass, the president reiterated last night, but there is no proof that increasing coverage expands access to health care. In Canada and Europe, the opposite is true.

The American public is no longer accepting the same tired platitudes, as evidenced by the Massachusetts election and the current climate around the country.

There are crucial problems not being addressed by health reform: First, there is a big shortage of doctors throughout the country, which will interfere with access to health care no matter your insurance coverage. The Association of American Medical Colleges estimates a shortage of 150,000 doctors by 2025.

Second, a one-size-fits-all HMO-style insurance is expensive and easily overused. It lacks the built-in disincentive for overuse of cheaper, higher-deductible insurance. Extending low-deductible insurance (a central principle of all the health reform bills) will lead to higher premiums, especially without portability to promote competition.

Third, even if you already have insurance it will be choked by government regulations and oversight under the new health insurance system, and it isn't likely to cover the high tech solutions you need. Lastly, doctors are already overwhelmed with too many patients. With no tort reform and decreasing reimbursements, they are likely to quit or at least quit taking insurance.

By not acknowledging America's concerns about health reform Wednesday night, the president appeared inflexible and incapable of real compromise. And by not spending much time on a topic that was front and center just a few weeks ago, he looked more like a politician than a leader.

Marc Siegel, MD

Unions Rally to Oppose a Tax on Health Insurance

When millions of blue-collar workers were leaning toward John McCain during the 2008 campaign, labor unions moved many of them into Barack Obama’s column by repeatedly hammering one theme: Mr. McCain wanted to tax their health benefits.

But now labor leaders are fuming that President Obama has endorsed a tax on high-priced, employer-sponsored health insurance policies as a way to help cover the cost of health care reform. And as Senate and House leaders seek to negotiate a final health care bill, unions are pushing mightily to have that tax dropped from the legislation. Or at the very least, they want the price threshold raised so that the tax would affect fewer workers.

Labor leaders say the tax would hit not only wealthy executives with expensive health benefits, but also many rank-and-file union members who have often settled for lower wage increases in exchange for more generous health benefits.

The tax would affect individual insurance policies with annual premiums above $8,500 and family policies above $23,000, which by one union survey would affect one in four union members.

The House bill does not contain such an excise tax, and many House Democrats oppose adding it to the combined House-Senate legislation. But the tax is a critical revenue component in the Senate’s bill. If the bill does too little to cover its costs, it might be defeated. Many economists support the tax, saying it will help hold down costs.

With labor groups warning that the tax will infuriate a key part of the Democratic base — union members — President Obama has agreed to meet with several top labor leaders on Monday to address their concerns and try to defuse their anger. The group includes the presidents of the A.F.L.-C.I.O., Teamsters and the steelworkers’ and service employees’ unions.

But whether the tax is negotiable remains unclear. Not only has Mr. Obama specifically endorsed the idea, but the White House and Senate leaders see the tax as pivotal in paying for the health care overhaul and addressing runaway health care costs.

Many Democrats and union officials fear that if both sides dig in on the issue, it could create a rift between the White House and labor — with some union leaders hinting they might lobby aggressively against the entire health care bill if it contains such a tax.

Union leaders have repeatedly warned the White House about the strong rank-and-file dismay, which could hurt the Democrats in Congressional elections this fall, especially in battleground states like Ohio, Pennsylvania and Wisconsin.

Ron Gay, an AT&T repairman in Youngstown, Ohio, who spent much of the summer of 2008 urging co-workers to vote for Mr. Obama, said, “If this passes in its current form, a lot of working people are going to feel let down and betrayed by our legislators and president.”

The Congressional Budget Office estimates that 19 percent of workers — or about 30 million employees — would be affected by the tax in 2016. Economists say most of them would be nonunion, although it is organized labor that has the lobbying clout to take a stand.

In recent days, labor’s strategy has become clear. Unions are urging their members to flood their representatives with e-mail messages and phone calls in the hope that the House will stand fast and reject the tax. The A.F.L.-C.I.O., a federation of nine million union members, has declared next Wednesday “National Call-In Day” asking workers to call their lawmakers to urge them not to tax health benefits. The International Brotherhood of Teamsters is urging members to tell their representatives that “such a tax is simply a massive middle-class tax hike that this nation’s working families should not be forced to endure.”

Many Democrats fear that enacting the tax will hurt their re-election chances.

“This would really have a negative impact on the Democratic base,” said Representative Joe Courtney, Democrat of Connecticut, who has enlisted 190 House Democrats to sign a letter opposing the tax. “As far as the message goes, it’s a real toughie to defend.”

While union leaders would prefer killing the tax, some say privately that they could live with it if the threshold is lifted to $27,000, say, or $30,000. They argue that many insurance policies above $23,000 are typical of the coverage in high-cost areas like New York or Boston, or policies that cover small businesses or employers with older workers.

According to a union survey, one in four members would be hit by a $23,000 threshold, but only one in 14 if the threshold were raised to $27,000.

White House officials, however, voice concern that raising the threshold that much would lose $50 billion of the $149 billion in revenue that the tax is expected to generate over 10 years.

Health overhaul bill facing court challenges

It now appears that some form of a health care bill will be passed unilaterally by congressional Democrats. But the fat lady has yet to warm up. Key provisions in the bill could be unconstitutional and need to be challenged. It could be a close constitutional call, as there are arguments on both sides.

Those who framed and ratified the Constitution intended to create a system of enumerated powers where all powers not specifically delegated to the federal government remained with state and local governments, and the people. Defenders of the individual mandate, requiring all Americans to have health insurance, cite the taxing power of the 16th Amendment and the commerce clause as the enumerated powers for this mandate.

In 1994, the Congressional Budget Office (CBO) opined: “The mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action. The government has never required people to buy any good or service as a condition of lawful residence in the United States.” But the CBO is a budget office, not a legal office issuing a historical statement about policy.

Individuals not carrying health insurance will be fined and possibly subjected to other penalties by the Internal Revenue Service. However, Congress has been careful not to call this a “fine,” but rather a “tax,” permissible under the 16th Amendment that authorized the federal income tax (“the Congress shall have power to lay and collect taxes on incomes, from whatever source derived”).

Such a tax would be discriminatory against individuals without health insurance, but defenders would counter that a graduated, discriminatory income tax schedule has been in effect since 1913, with those in higher-income tax brackets paying more taxes at a higher percentage rate. Hence, the 14th Amendment's equal protection clause may or may not be applicable to the individual mandate.

The 5th Amendment's takings clause may also be operative in that the government is, in a very real sense through the individual mandate, taking the individual's private property, in the form of his or her income, to buy insurance.

The commerce clause was initially intended by the framers to free up interstate commerce, specifically trade among the 13 Colonies, which had erected trade barriers. Following the New Deal and the Supreme Court-packing scandal, federal courts frequently defined the commerce clause as permitting regulations governing all commercial activity, far beyond the scope of interstate trade.

However, several recent decisions have revived some limits on the clause, such as United States v. Lopez. In this 1995 case, the Supreme Court held the commerce clause does not authorize a federal law banning guns in local school zones.

Critics of the Senate health care bill have also argued that the bill violates the equal protection clause by legislating unequal treatment among the states. Several “sweetheart” deals were arranged to secure passage of the bill — for example, the so-called “Cornhusker Kickback” in which the state of Nebraska was given a permanent waiver for any expanded state Medicaid costs mandated by the bill. Poor states will subsidize this discriminatory bailout.

But defenders of the bailouts will counter that state earmarks have been business as usual for decades by both Democrats and Republicans.

Even if Congress passes a health care bill on the grounds that it passes constitutional muster under the equal protection clause, the takings clause and the commerce clause, Congress does not have the final say: The courts do. We learned this from Marbury v. Madison, where the Supreme Court ruled an act of Congress unconstitutional. The courts today could indeed rule portions of the health care bill in violation of the 14th and 5th Amendments and/or the commerce clause.

The bill must be challenged in court. Forcing Americans to buy a certain private-sector product is an overdose of big government that may be toxic to the plain meaning and intent of the Constitution.