[Senate Hearing 111-1041]
[From the U.S. Government Publishing Office]
S. Hrg. 111-1041
WHAT WOMEN WANT: EQUAL BENEFITS FOR EQUAL PREMIUMS
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
ON
EXAMINING EQUAL HEALTH CARE FOR EQUAL PREMIUMS, FOCUSING ON WOMEN
__________
OCTOBER 15, 2009
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
CHRISTOPHER J. DODD, Connecticut
BARBARA A. MIKULSKI, Maryland
JEFF BINGAMAN, New Mexico
PATTY MURRAY, Washington
JACK REED, Rhode Island
BERNARD SANDERS (I), Vermont
SHERROD BROWN, Ohio
ROBERT P. CASEY, JR., Pennsylvania
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
MICHAEL F. BENNET, Colorado
MICHAEL B. ENZI, Wyoming
JUDD GREGG, New Hampshire
LAMAR ALEXANDER, Tennessee
RICHARD BURR, North Carolina
JOHNNY ISAKSON, Georgia
JOHN McCAIN, Arizona
ORRIN G. HATCH, Utah
LISA MURKOWSKI, Alaska
TOM COBURN, M.D., Oklahoma
PAT ROBERTS, Kansas
J. Michael Myers, Staff Director and Chief Counsel
Frank Macchiarola, Republican Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
THURSDAY, OCTOBER 15, 2009
Page
Murray, Hon. Patty, a U.S. Senator from the State of Washington,
opening statement.............................................. 1
Prepared statement........................................... 2
Burr, Hon. Richard, a U.S. Senator from the State of North
Carolina....................................................... 3
Brown, Hon. Sherrod, a U.S. Senator from the State of Ohio....... 4
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of
Pennsylvania................................................... 6
Franken, Hon. Al, a U.S. Senator from the State of Minnesota..... 7
Prepared statement........................................... 8
Mikulski, Hon. Barbara A., a U.S. Senator from the State of
Maryland....................................................... 10
Hagan, Hon. Kay R., a U.S. Senator from the State of North
Carolina....................................................... 10
Prepared statement........................................... 11
Guest, James, President and CEO, Consumers Union, Yonkers, NY.... 15
Prepared statement........................................... 17
Furchtgott-Roth, Diana, Senior Fellow, Hudson Institute, and
Director, Center for Employment Policy, Washington, DC......... 21
Prepared statement........................................... 23
Crouse, Janice Shaw, Ph.D., Director and Senior Fellow, Concerned
Women for America, Washington, DC.............................. 28
Prepared statement........................................... 29
Greenberger, Marcia F., Founder and Co-President, National
Women's Law Center (NWLC), Washington, DC...................... 33
Prepared statement........................................... 35
Buchanan, Amanda, Patient/Health Care Consumer, Weiser, ID....... 45
Prepared statement........................................... 47
Robertson, Peggy, Patient/Health Care Consumer, Centennial, CO... 48
Prepared statement........................................... 49
Ignagni, Karen, President and CEO, America's Health Insurance
Plans (AHIP), Washington, DC................................... 50
Prepared statement........................................... 51
Merkley, Hon. Jeff, a U.S. Senator from the State of Oregon...... 57
Bennet, Hon. Michael F., a U.S. Senator from the State of
Colorado....................................................... 62
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Senator Enzi................................................. 71
Washington Post article...................................... 71
Letters from:
North Carolina Department of Insurance to Senator Burr... 72
Consumers Union to Senator Mikulski...................... 73
Response to Question of Senator Merkley by Jim Guest......... 74
(iii)
WHAT WOMEN WANT: EQUAL BENEFITS FOR EQUAL PREMIUMS
----------
THURSDAY, OCTOBER 15, 2009
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 10:33 a.m. in
Room SD-430, Dirksen Senate Office Building, Hon. Barbara A.
Mikulski, presiding.
Present: Senators Mikulski, Murray, Brown, Casey, Hagan,
Merkley, Bennet, Franken, and Burr.
Opening Statement of Senator Murray
Senator Murray. This hearing will come to order. Senator
Mikulski will be chairing this committee, but she is running
late and asked me to go ahead and get it started, so we could
get opening statements going. I just want to express my
appreciation to Senator Mikulski and for all of our colleagues
who are here today for this hearing, where we are going to be
talking about a topic that impacts not only women, but families
and entire communities.
You know, when the rising cost of health insurance hits
women, it hurts our Nation. For the millions of women across
this country who open up the mail every month to see their
premiums go up, or who cannot get the preventive care like
mammograms because the co-pays are too high, or who work part-
time or for a small business that doesn't provide insurance, or
can't get covered for maternity health care, or, worst of all,
forced to stay in an abusive relationship because if they leave
they or their children lose coverage, we really have to be the
voice of those women.
Today we are having this hearing to ask the questions that
women and families and businesses across America are asking.
Some of you in this room have heard me tell the story of a
young boy I met by the name of Marcellas Owens from my home
State--I met him back in the spring--who told me that he is
watching me every day to see what we're going to do with this
health care bill, because he has a very tragic story. His mom,
whose name was Tiffany, got sick and, because she was sick, she
lost days at work and her employer said: ``If you can't come to
work, we're going to fire you.'' She worked for a fast food
restaurant. She had three kids and had health coverage through
that fast food restaurant.
In September 2006, because she missed so much work, she
lost her job, and with that she lost her health care coverage.
When she lost her health care coverage, she could not go to the
doctor any more, and as a result of that Tiffany lost her life.
Marcellas, the little boy, told me last spring that he is
going to be watching me to make sure that no other little boys
lose their mom. That's what this health care debate is about,
because our system really is broken. Women like Tiffany, across
the country who are moms, shouldn't lose their health care
because they are sick, and we need to make sure that this
system works for them and for women who are denied coverage or
charged more because of preexisting conditions, conditions like
pregnancy or C-sections or domestic violence.
Our system is broken when insurance companies charge women
of child-bearing age more than men, but they don't cover the
maternity care anyway, or only offer it for hefty additional
premiums. Women and their families and businesses need health
insurance reform and that's why we're working so hard on this.
We know that health reform will help women by ending
discrimination based on gender rating or gender-biased
preexisting conditions, by covering maternity care, by covering
preventive care and screenings, including mammograms and well-
baby care, by expanding access to coverage even if an employer
doesn't offer it, and making family health decisions, which are
frequently made by women, by setting up a health insurance
exchange.
There is a lot in the health care reform that is very
important to women, and we're having this hearing today to talk
about those issues in particular as we move forward on this.
Again, Senator Mikulski will be joining us in just a few
minutes, but I will turn to our colleagues for their opening
statements and then, if she's not here, we'll turn to our
witnesses to begin.
[The prepared statement of Senator Murray follows:]
Prepared Statement of Senator Murray
Thank you, Senator Mikulski, for holding this hearing.
And thanks to all of our colleagues for attending to
discuss a topic that impacts not only women, but families and
entire communities.
Because when the rising cost of health insurance hurts
women, it hurts our Nation.
And for the millions of women across America--
who open the mail each month to see premiums go
up,
who can't get needed preventative care like
mammograms because the co-pays are too much,
who work part time or for a small business that
doesn't provide insurance,
who can't get covered for critical maternity care,
or
who are forced to stay in abusive relationships
because if they leave, they or their children will lose health
care coverage--we are their voice.
And today we are asking the questions that women and
families and businesses across America are asking.
Many of you in this room have heard me tell the story of a
little boy named Marcellas Owens from my home State of
Washington whose mom, Tifanny, got sick and lost her life
because of the high cost of health insurance.
Tifanny was a single mom who felt strongly about working to
support her three children. She had health care coverage
through her job at a fast food restaurant. But, in September
2006 she got sick and started to miss a lot of work.
Her employer gave her an ultimatum: make up the lost time
or lose your jobs. Well, because of her illness, Tifanny
physically couldn't make up the time and she lost her job and
with it went her insurance.
As we have seen time and time again, women are charged
nearly 50 percent more than men in the insurance market--and
with a pre-existing condition it would be almost impossible to
get coverage anyway.
Without the coverage and care she needed, in June 2007,
Tifanny lost her life and Marcellas and his sisters lost their
mom.
Our health care system is broken.
It's broken for women and moms like Tifanny who work to
provide for their families but are charged nearly 50 percent
more than men for health care in the individual market.
It's broken for women who are denied coverage or charged
more for ``Pre-Existing Conditions'' like:
``Pregnancy,''
``C-Sections,'' or
``Domestic violence.''
It's broken when insurance companies charge women of child-
bearing age more than men but still don't cover maternity care.
Or only offer it for hefty additional premiums.
The status quo isn't working.
Women and their families and businesses need health
insurance reform now.
Reform will help women by:
Ending discrimination based on gender-rating or
gender-biased ``pre-existing conditions.''
Covering maternity care.
Covering preventative care and screenings--
including mammograms and well-baby care.
Expanding access to coverage even if an employer
doesn't offer it and making family health decisions--which are
frequently made by women--easier by setting up a health
insurance exchange.
For women across this country, and for their families, our
businesses, and our Nation's future strength, we have to reform
our health insurance system this year.
I want to thank Senator Mikulski again for her dedication
to this issue and I look forward to hearing from all of today's
witnesses.
With that, Senator Burr, if you would like to make an
opening statement.
Statement of Senator Burr
Senator Burr. Thank you, Senator Murray. I want to thank
you and Senator Mikulski for chairing this hearing this
morning. I also want to thank our witnesses for their
willingness to come in, to travel on a very messy day in
Washington, DC, probably most of the country. It's a sure sign
that the season's changing as they call for snow just 60 miles
away from here.
In many families women are the primary health care
decisionmaker for their loved ones. I appreciate having the
opportunity today to discuss more specifically how health care
reform would impact women across North Carolina and, more
importantly, across our country. Today's hearing will help us
inform our continued work on health care reform.
As I've told my constituents and colleagues many times in
recent months and weeks, I agree that we need meaningful,
meaningful health care reform. I was proud to join my Senate
colleague Tom Coburn earlier this year when we introduced the
first comprehensive legislation to fundamentally reform our
health care system.
The Patients' Choice Act is based on the principle of
promoting universal access to quality and affordable health
care for all. Our bill avoids a one-size-fits-all government-
run program, instead promoting choice for every American
regardless of their income or employment, so that they can
access a health plan that meets their income, their health
needs, their conditions.
The Patients' Choice Act restores the idea of portability
to health coverage. If you move or change jobs, you don't lose
your health insurance. And we create State insurance exchanges
to give Americans a one-stop marketplace to compare different
health insurance policies and the ability to select the one
that meets their unique health needs.
The Patients' Choice Act also moves our Nation away from
our current health system that's been plagued by sick care for
far too long, by promoting prevention, wellness, and chronic
disease management. For example, we provide incentives for
States to reduce rates of chronic disease like heart disease,
the leading cause of death for both women and men in our
Nation. And our legislation is sustainable for generations to
come.
I think another important element that should be part of
this discussion is medical malpractice reform. If we care about
making sure women have access to OB-GYNs, we cannot ignore the
fact that high malpractice insurance is driving doctors out of
this specialty and, even worse, closing their practices or
forcing them to migrate to urban areas only.
I hope this issue is part of the discussion today because
it is the 800-pound gorilla in the room when it comes to access
to affordable health care for women. Any serious piece of
health care reform legislation must include these essential
principles.
I look forward to continuing to work with my colleagues on
health reform to ensure that constituents across North Carolina
and, more importantly, this country have access to quality and
affordable health care.
I thank the chair.
Senator Murray. Thank you.
Senator Brown.
Statement of Senator Brown
Senator Brown. Thank you, Senator Murray, and thanks to
Senator Mikulski for calling this hearing. Thank you all, the
seven of you, for joining us today.
There's been a lot of attention this year, as we know, to
the need for health reform, but there's been too little
attention focused on how health reform will work to improve the
health and well-being of more than half our Nation's
population, America's women. Our Nation's made significant
progress toward equal treatment of men and women. We've passed
legislation promoting equitable wages for the same work
regardless of gender. We've passed legislation to prohibit
gender discrimination in education and athletics. We've passed
legislation to end housing discrimination on the basis of sex.
We've passed legislation to provide compensation for victims of
sexual harassment. We've passed legislation to end pregnancy
discrimination in employment.
However, we've yet to pass legislation to end gender
discrimination in health insurance coverage and to bridge the
gender gap that exists so troublingly in our health care
system. It's simply unacceptable that in a nation which has
made such great strides with respect to women's rights,
something we trumpet all over the world, that we allow more
than 20 million American women and girls to go without health
insurance each year.
In 2007, 14 percent of all women in my State of Ohio were
uninsured. Part of the reason that so many women are uninsured
stems from the fact that women are less likely to be employed
full-time, especially full-time in jobs with health care
benefits, making them less likely to be eligible for employer-
based health benefits.
Another part of the reason is that important State and
Federal laws that protect women with employer-sponsored
coverage don't protect women purchasing health insurance in the
individual market. For instance, in the private health market,
insurance companies are allowed to deny care or charge higher
premiums based on gender, history of domestic violence, or
preexisting conditions such as pregnancy. As a result, women
are often charged higher premiums than men.
In Columbus, the capital of my State, a 30-year-old woman
pays 49 percent more than a man of the same age for Anthem's
Blue Access Economy Plan. The woman's monthly payment is
$92.87; a man pays $62.30. At age 40, women pay 38 percent more
than men for that policy.
Compounding this premium hardship is the sad reality that
women are generally poorer than men. In Ohio, women earn just
74 cents for every dollar a man earns. Insurers in Ohio and
most parts of the country are also allowed to exclude coverage
for preexisting conditions. For example, if a woman previously
had a C-section, insurers are allowed to refuse to pay for
future C-sections or reject her application altogether due to a
supposed preexisting condition. In 2006, close to a third of
all births in Ohio were by C-section, meaning that tens of
thousands of women could face coverage exclusions or rejections
because of these preexisting condition exclusions.
Health reform will finally put an end to these practices,
which curtail access to, and undercut the value of, health
insurance for women. No more gender discrimination in premiums;
no more coverage denials because of preexisting conditions; no
more exploitation of a woman's history, particularly a history
of being victimized by domestic violence--all to inflate
premiums going forward.
I would add that a public option is important to ensure
these rules are indeed enforced. Health reform will then ensure
coverage of basic health services, including maternity
benefits. Health reform will place a cap on the costs insurance
companies charge and, that insurance companies can shift to
their enrollees.
One of the industry's smoothest tricks is to market a full
loaf to get you to purchase coverage to protect against
unanticipated health spending, but when you get sick what's
unanticipated is how little your insurance actually covers. We
all have stories. I go to the Senate floor night after night
and read letters from people in Lima and Mansfield and Toledo
and Cincinnati, people who thought they had really good
insurance until they got really sick and found out their
insurance wasn't what they thought it was.
That's why this health insurance legislation is so
important. That's why the work of all of you on this panel is
so important, to make sure that these problems that we've had
in this country for decades are a thing of the past.
Thanks.
Senator Murray. Thank you.
Senator Casey.
Statement of Senator Casey
Senator Casey. First of all, I want to thank Senator Murray
for chairing our hearing, and Senator Mikulski for her
leadership.
I will echo, but not reiterate, a lot of what Senator Brown
said about so much of the work that's been done this year in
the Senate, in both the HELP Committee and the Finance
Committee. I note two provisions among many, but two that we
worked on in the HELP Committee. One was 2701, prohibiting
insurance rating based upon gender, which of course leads to
bad outcomes for women across the board.
Senator Brown mentioned just the issue of domestic
violence. The idea that that would be a bar to coverage, that
that would prevent a woman from getting the kind of health care
coverage that she should have a right to expect, is really
horrific. In the case of a victim of domestic violence, it's
the ultimate betrayal, and then she gets betrayed again because
the system doesn't give her the kind of coverage and/or
treatment that she should have a right to expect.
The Office of Women's Health was also part of the HELP
bill. Obviously, in the Finance Committee more work was done as
well. I was on the HELP Committee, so I tend to favor that
bill. I voted for it.
But I think between the two committees we can make
tremendous progress on a whole host of issues that relate to
women, but in particular those issues that center on the kind
of coverage that all of us should have a right to expect. But
the idea that we're still allowing gender discrimination to go
on when we have the power to fix it at long last is
particularly disturbing.
This is the year that we will not only vote on a health
care bill, but it's the year at long last that we correct that
continuing problem for women as it relates to the kind of
coverage they get.
There's a lot more to talk about. I know that many of us
have worked on--as I was a co-sponsor of the Women's Hospital--
Women's Hospitals, plural, Education Equity Act, which among
other things would create a $12 million funding pool for
graduate medical education for small women's hospitals, it also
requires hospitals to report annually on the status of the
residency training programs. Senator Whitehouse has led on this
and others have helped as well.
We have to continually look for opportunities to make
progress, but the most important thing we can do this year, I
believe, is to make sure that no more gender discrimination
occurs in our health insurance policies.
With that, Senator Murray, thank you for chairing the
hearing.
Senator Murray. Thank you.
Senator Franken.
Statement of Senator Franken
Senator Franken. Thank you, Senator Murray. And I want to
thank Chairwoman Mikulski for holding today's hearing on this
crucial topic of how health reform will improve the lives of
American women. I believe that women's health is fundamental to
our country's health because women are the small business
owners and entrepreneurs, they are the educators, doctors, and
CEOs. As mothers and grandmothers, women are often also the
health care decisionmakers for our families.
It is of utmost importance that the national health reform
legislation makes a real difference in the lives of American
women across their entire lifespan. As others on the committee
have mentioned, women are among those most severely
disadvantaged in our current health system. Right now, health
insurance companies discriminate against women solely on the
basis of their gender. Right now it is legal in many States for
health insurance companies to charge women higher premiums or
deny coverage altogether if they are, for example, survivors of
domestic violence, as Senators Brown and Casey have spoken to.
Instead of providing the care and support that victims need
in order to get out of abusive situations and stay healthy,
health insurance companies actually punish these women. This is
simply amoral and unacceptable.
It is also unbelievable to me that in this day and age we
allow insurance companies to charge women more for health
insurance simply because of the fact that they may become
pregnant. I heard recently from a woman named Jessica in
Minneapolis. Jessica is 35 years old and works as an
independent contractor. When she started her business she knew
that it was important to have health insurance, of course, and
she wanted to do the responsible thing, so she looked into
buying an individual health plan.
She found two main options, both of which had the same
benefits except for one thing: maternity care. The plan that
included maternity services cost about twice as much and was
unaffordable for her. Right now she doesn't have any children,
but she thinks she might like to become pregnant some time in
the next few years. But as she was considering these individual
health coverage options, Jessica found out that to get the
pregnancy coverage she would also need to be enrolled in the
maternity coverage for 18 months before becoming pregnant.
Otherwise her pregnancy would be considered a preexisting
condition and would not be covered.
Health insurance companies consider pregnancy a preexisting
condition, and as far as I know it's only one that women can
have. We permit this discrimination under current law.
Now, Jessica is a young entrepreneur, exactly the type of
smart and innovative business person that we want to encourage
in Minnesota. But this ridiculous practice of charging women
more for health insurance sends a message that we don't want
women to receive prenatal services and high quality maternity
care, as if we don't all benefit from healthy mothers and
healthy babies.
The reality is that if my wife or your sister doesn't have
access to high quality affordable health care, that's bad for
all of us, bad for our economy, our country, and our future.
Fortunately, when we pass national health reform we will
begin a new era in women's health. For the first time, women
will have access to comprehensive health benefits, including
maternity care, without having to pay more than their male
counterparts. This is a huge step forward for justice in our
country and it's one of the main reasons why we must pass
health reform this year.
It's also a top priority for me that health reform includes
a crucial women's health service, access to affordable family
planning services. These services enable women and families to
make informed decisions about when and how they become parents.
Access to contraception is a fundamental right of adult
Americans, and when we fulfil this right we're able to
accomplish a goal that we all share on both sides of the aisle,
to reduce the number of unintended pregnancies.
I believe that affordable family planning services must be
a part of the final implementation of health reform
legislation. I look forward to working with all of my
colleagues here to ensure that we make this a reality for all
women in America.
Senator Murray and Senator Mikulski, I appreciate the
opportunity to participate in today's discussion and look
forward to hearing from all of our witnesses. Thank you all for
being here today.
Madam Chairwoman.
[The prepared statement of Senator Franken follows:]
Prepared Statement of Senator Franken
Thank you, Madam Chairwoman. And thank you for holding
today's hearing on this crucial topic of how health reform will
improve the lives of American women. I believe that women's
health is fundamental to our country's health because women are
small business owners and entrepreneurs; they are educators and
doctors and CEOs. And as mothers and grandmothers, women are
often also the health care decisionmakers for our families. It
is of utmost importance that national health reform legislation
makes a real difference in the lives of American women, across
their lifespan.
As others on the committee have mentioned, women are among
those most severely disadvantaged in our current health system.
Right now, health insurance companies discriminate against
women solely on the basis of their gender. And right now, it's
legal in many States for health insurance companies to charge
women higher premiums--or deny coverage all together--if they
have a history of domestic violence. Instead of providing the
care and support that victims need in order to get out of
abusive situations and stay healthy, health insurance companies
punish them. This is simply immoral and unacceptable.
It is also unbelievable to me that, in this day and age, we
allow insurance companies to charge women more for health
insurance simply because of the fact that they may become
pregnant. I heard recently from a woman named Jessica in
Minneapolis. Jessica's 35 years old and works as an independent
contractor.
When she started up her business, she knew that it was
important to have health insurance. She wanted to do the
responsible thing so she looked into buying an individual
health plan. She found two main options, both of which had all
of the same benefits except for one thing: maternity care. And
the plan that included maternity services cost about twice as
much and was unaffordable.
Right now, she doesn't have any children but she thinks she
might like to become pregnant sometime in the next few years.
But as she was considering these individual health coverage
options, Jessica also found out that to get the pregnancy
coverage, she would also need to be enrolled in the maternity
coverage for 18-months before becoming pregnant. Otherwise, her
pregnancy would be considered a preexisting condition and would
not be covered. Health insurance companies consider pregnancy a
preexisting condition. And we permit this discrimination under
current law.
Jessica is a young entrepreneur--exactly the type of smart
and innovative businessperson that we want to encourage in
Minnesota. But this ridiculous practice of charging women more
for health insurance sends the message that we don't want women
to receive prenatal services and high-quality maternity care.
As if we don't all benefit from healthy mothers and babies. The
reality is that if my wife or your sister doesn't have access
to high-quality, affordable health care, that's bad for all of
us--bad for our economy, our country and our future.
Fortunately, when we pass national health reform, we will
begin a new era in women's health. For the first time ever,
women will have access to comprehensive health benefits,
including maternity care--without having to pay more than their
male counterparts. This is a huge step forward for justice in
our country, and it's one of the main reasons why we must pass
health reform this year.
It is also a top priority for me that health reform
includes a crucial women's health service--access to affordable
family planning services. These services enable women and
families to make informed decisions about when and how they
become parents. Access to contraception is a fundamental right
of adult Americans. And when we fulfill this right, we are able
to accomplish a goal that we all share, on both sides of the
aisle--to reduce the number of unintended pregnancies. And so I
believe that affordable family planning services must be part
of the final implementation of health reform legislation. I
look forward to working with all of my colleagues here to
ensure that we make this a reality for all women in America.
Madam Chairwoman, I appreciate the opportunity to
participate in today's discussion and look forward to hearing
from all of our witnesses.
Statement of Senator Mikulski
Senator Mikulski. Well, good morning, everybody.
I'll kind of be the wrap-up speaker. The vagaries of the
Baltimore-Washington Parkway delayed my arrival. But I will now
turn to Senator Hagan and then I'll say a few words, and then
we look forward to hearing from our excellent panel.
Statement of Senator Hagan
Senator Hagan. Thank you, Madam Chairwoman. Thanks so much
for holding this hearing today. I think that it's critical that
we highlight the disparities in affordable health insurance
options between men and women.
Recently I received communications from several women in
North Carolina. One woman in particular, when she was 27 years
old she was diagnosed with breast cancer. She had a 16-month-
old son and this woman was in an extremely abusive
relationship. It was interesting, too: Her husband knew that
she could not leave him because of her breast cancer and that
she had to have his employer-provided health insurance.
She looked into individual insurance plans, but her breast
cancer obviously was considered a preexisting condition. For 7
years this woman stayed in this abusive relationship.
Another woman called me about her sister, and the sister,
who was uninsured, had waited years between mammograms because
she couldn't afford to pay for the out-of-pocket screenings.
She found a lump in her breast. What happened, the lump became
a mass, she finally got a mammogram, and she paid for that with
cash. The mammogram confirmed what she had suspected, that she
did have breast cancer. Once she had that diagnosis, she still
was unable to get the treatment she needed.
She ended up passing away last March. Her sister obviously
feels that had she had preventive care, early detection, that
perhaps she could still be with us today.
Unfortunately, we hear about these cases far too often. I
think the inefficiencies and discriminatory practices in our
health care system disproportionately affect women. In all but
12 States, insurance companies are allowed to charge women more
than they charge men for coverage. I think some other people
have already said it, that the great irony is that so many
people who are being obviously cared for by women and mothers,
these women are penalized under our current system.
I have two children in their early 20s, one male, one
female. Guess what, the female is paying lots more for private
health insurance than her brother. I had a 23-year-old staff
member look up--she's from Fayetteville--look for health
insurance on the open market. The best-selling plan with the
$2,700 deductible that she could find would cost her $235 a
month. For men of the same age, it was $88 a month, more than
2\1/2\ times as expensive.
We looked up in Maryland, too, Senator Mikulski, you might
be interested, one of the few States that prohibits gender
rating. A basic health plan there costs as low as $37 a month
both for men and women.
After overcoming some of the cost and preexisting
qualifying hurdles, many women who have health insurance are
still stuck because some of the preventive screenings--
mammograms, Pap smears--are not covered as preventive care, and
often the co-pays for these extremely critical services are
extremely high. In many cases, the difference between life and
death is early detection. I think we all know that. I think
everything we can do to give preventive screenings will pay
off.
I also heard from a hospital in North Carolina that
recently implemented a wellness program. A few years ago this
CEO was meeting with about 20 to 30 of the nursing assistants,
who were earning at the lower wage of the hospital. The CEO
asked the group of those who were there who were old enough to
require a mammogram how many had had one. Only 20 percent of
these women said that they'd had one and the rest said, due to
the out-of-pocket cost and the other financial items that they
were juggling, food for their children, paying rent, et cetera.
After that meeting, the CEO said that the hospital decided
to remove that cost-sharing barrier for those preventive
services, which I think is a plus.
The bill that we put forward in this committee, the
Affordable Health Choices Act, makes preventive care possible
for women across America, and it eliminates the co-pays and the
deductibles for these recommended preventive screenings.
I also think that we need to really look at the fact that
so many places around our country, insurance companies are
charging women more than men, whether it's just for basic
coverage, and then obviously a separate item on maternity
coverage; and that using these preexisting conditions as a
reason to deny anyone health insurance is unacceptable.
Madam Chairman, thanks for holding this committee meeting
and I look forward to hearing from our witnesses today.
[The prepared statement of Senator Hagan follows:]
Prepared Statement of Senator Hagan
Madame Chairwoman, thank you for holding this hearing
today.
I think it is critical that we highlight the disparities in
affordable health insurance options among men and women.
Recently, I received two e-mails highlighting the real word
ramifications of health insurance inequities between men and
women.
A few weeks ago, I received a heartbreaking e-mail from a
young woman from North Carolina. When this woman was 27, she
was diagnosed with breast cancer. She had a 16-month-old son,
and was in an extremely abusive relationship.
Her husband knew she wouldn't leave him because she
couldn't afford her medical treatment without his employer-
provided health insurance.
This woman looked into individual insurance plans, but her
breast cancer was considered by insurance companies to be a
preexisting condition. For 7 years, her husband kept her in
this abusive relationship by threatening to take her off his
insurance plan.
I also received an e-mail from a woman in Raleigh, NC about
her sister, who was uninsured and waited years between
mammograms because she couldn't afford to pay for out-of-pocket
screenings. She found a lump in her breast.
By the time the lump became a mass, Julie's sister finally
got a mammogram--and had to pay for it with cash. The mammogram
confirmed what she suspected--that she had breast cancer. But
now that she had a diagnosis, she had no way to pay for the
treatment.
Julie's sister lost her battle with breast cancer this
March. Like thousands of women across America, Julie's sister
probably could have beaten this cancer if she had access to
affordable preventive care and, after her diagnosis, access to
insurance to cover her cancer treatment.
In this heartbreaking situation, Julie's sister was sick
and stuck.
Unfortunately, I hear about cases like these far too often.
Inefficiencies and discriminatory practices in our health care
system disproportionately affect women.
In all but 12 States, insurance companies are allowed to
charge women more than they charge men for coverage. The great
irony here is that mothers, the people who care for us when we
are sick, are penalized under our current system.
My daughter Carrie recently graduated from college and had
to purchase her own insurance. For no other reason than her
gender, insurance policies cost more for Carrie than they do
for my son, Tilden.
For a 23-year-old, healthy female from Fayetteville, NC
shopping for health insurance on the individual market, the
most basic, best selling plan, would cost her $235 a month. For
a man of the same age, it would cost $88 a month. That's more
than 2\1/2\ times more expensive.
While some argue that females cost the health care system
more in medical costs, these discrepancies are steep.
Especially if you consider in Maryland, one of the few States
that prohibit gender rating, a basic health plan costs as low
as $37 per month for both men and women.
After overcoming some of the cost and preexisting
qualifying hurdles, many women who have health insurance are
still stuck. Insurance companies often don't cover key
preventive care services--ranging from mammograms to pap
smears. And often the co-pays for these critical services are
extremely high.
One in five women over the age of 50 has not received a
mammogram in the past 2 years. More than half of all women,
like Julie's sister, have reported delaying preventive
screenings because of the exorbitant cost.
In many cases, the difference between life and death is
early detection.
I heard from one of the hospitals in North Carolina which
recently implemented a wellness program. A few years ago, the
CEO of this hospital was meeting with about 20 to 30 nursing
assistants who were earning relatively low wages. The CEO asked
the group of those who were old enough to require a mammogram,
how many had. Only 20 percent said they had and the rest said
they could not afford the out-of-pocket costs with all the
other financial items that they were juggling, like food for
their children, paying rent, etc. After that meeting, the
hospital decided to remove the cost sharing barriers for
preventive services.
The Affordable Health Choices Act, which came out of this
committee, makes preventive care possible for women across
America. It eliminates all co-pays and deductibles for
recommended preventive services.
We also are stopping insurance companies from charging
women more than men--or using preexisting conditions as a
reason to deny anyone health insurance.
I look forward to hearing from our witnesses today.
Senator Mikulski. Well, good morning to everybody. I
apologize for being late. It was not only the traffic, but, as
you can see, I'm now looking at the health care system from the
wheelchair up. A couple of months ago, coming out of mass, I
took a fall on some steps and broke my ankle in three places,
and have required extensive surgery and extensive
rehabilitation. I have seen health care from a patient's
perspective more up close and personal than I wanted; I also
have spent a lot of time talking to very talented providers,
from gifted surgeons to the physical therapists and GNAs; and I
also have been in the rooms with others who've had to seek
assistance, from knee replacements to amputations.
We know that health care is truly an American issue, where
we need to be able to guarantee access. Health reform is how we
achieve universal access in a way that meets quality standards
and also cost standards.
Along our way, as we've looked at this, we see that there
are other issues related to what appears to be discrimination
or redlining, and this is why we're holding our hearing today,
called Equal Benefits for Equal Premiums. I want to thank my
colleagues for their opening statements because they set the
tone that I was going to call for if I kicked it off, which is:
one, to welcome everyone, acknowledging that when coming to the
table we will have diverse views, just as they are among
ourselves here on the committee, and also at our witness table.
We welcome diverse views. That's how we arrive at what we
hope will be the sensible center in which we can achieve health
care reform that will provide the greatest range of access, but
at the same time recognizing the mandate for prudence when it
comes to cost to both our government, to insurance companies,
but most of all to American families.
We have here a representation on a bipartisan panel. We've
worked with Senator Burr, who is my ranking member on the
subcommittee, and we thank you for being here. We really
welcome your views and we want to hear them. What I will
guarantee is that this hearing from our side of the table will
be conducted with the utmost of civility. I believe that, in
order to arrive at that sensible center, we really need to
listen to each other and have a dialogue with each other.
In preparation for turning to our witness table, I just
wanted to note that every single panelist will be treated with
the utmost respect, dignity, and civility, because the issue is
too big, it's too serious, to get into petty, prickly disputes.
For me, health care definitely is a woman's issue. My
history goes back to my early days on this panel, when women
were excluded from the protocols at NIH. The famous study, take
an aspirin a day to keep a heart attack away, was done on
10,000 male residents, doctor residents, and not one woman was
included.
Thanks to working on a bipartisan basis, Senator Kennedy,
Senator Harkin, myself in the House, Senators then-
Congresswomen Snowe and Connie Morella, and working with a very
brilliant physician named Bernadine Healy, we were able to
change the paradigm and I believe have improved quality care
for women.
For us, health care as a woman's issue has been an
important part of this panel. Health care reform, we believe,
is a must-do woman's issue because so many women are affected
by health care and they also often drive the decisions that
families make about health care. And health insurance reform is
a must-change issue.
We've heard many of the facts presented by colleagues in
their opening statements, how we're concerned that women are
discriminated against, No. 1, in paying higher premiums; also
that often our life processes, like pregnancy, are treated as
preexisting conditions; and also the issue of prevention and
wellness often, because we want those much-needed screenings,
are high-cost or have other barriers.
My colleagues have given an excellent set of facts and I am
not going to repeat them. I think we can turn right to the
witnesses. But I can tell you where I'm heading, which is I
want to be able to listen to ideas and recommendations and
experiences, but one of the largest consumers of health care
are older women and, quite frankly, older Americans. At the end
of the day, when we conclude our deliberations and votes on
this, we want to save and strengthen Medicare.
No. 2, we want to eliminate those barriers to health
insurance. Particularly the issue of gender rating is of great
concern, where simply being a woman means you pay more.
No. 3, the very controversial issue of what is a
preexisting condition that could be a barrier to getting health
care. I was very concerned that simply being pregnant or having
a C-section often can result in paying far more, far more for
care.
Again, my colleagues have given the other facts and
statistics, which I won't repeat. But the fact remains that
women often pay more than their male counterparts: a 25-year-
old male in roughly the same condition often pays less than a
25-year-old female; and the fact of the matter is that
preexisting conditions like pregnancy or having had a C-section
could be a barrier to health insurance.
And No. 4, often those vagaries of life, like being a
battered woman, in eight States also means you can have a
harder time affording or obtaining health insurance.
What we want to be able to do, because this committee and
many at this table have fought for equal pay for equal or
comparable work, we want to be able to have equal or comparable
benefits for equal premiums.
I've said enough for now, and I want to turn to our
panelists. I thought maybe, rather than saying should we go in
alphabetical order or whatever, maybe we'll just start with Mr.
Guest and go all the way down and, Ms. Ignagni, wrap up with
you, and then we can go to our questions. What I'd like to do
is welcome Mr. Guest, the President and CEO of Consumers Union,
with a distinguished career in public service. We want to turn
to Diane Furchtgott-Roth of the Hudson Institute, Senior Fellow
on Employment Policy and also Lead Economist, who comes to us
having actually served as a staff member in President Reagan's
Council of Economic Advisers, and we look forward to her
testimony.
Janice Shaw Crouse of the Concerned Women of America, who's
also a Senior Fellow at the Beverly LaHaye Institute, and
worked for Dr. Lou Sullivan, the wonderful Secretary of HHS. We
miss seeing him as much as we used to. We welcome her and her
expertise.
Marcia Greenberger, the Founder and Co-President of the
National Women's Law Center, that has helped us, giving us many
of the ideas that helped us with the Lilly Ledbetter Fair Pay
Act and the Pregnancy Discrimination Act and so on.
Amanda Buchanan, who is a real live mother who has had to
face the significant issues of family and responsibility both
for herself and for her children.
Peggy Robertson, who also was someone who thought she had
health insurance, then had a C-section, which I know she'll
tell us about, and then what happened as she came up against
the insurance bureaucracies.
Then Karen Ignagni, President and CEO of the American
Health Insurance Plans. She herself was a professional staffer
here to a beloved member, Claiborne Pell, and actually worked
for the HELP Committee. Some might say, well, she's kind of a
proxy staffer now, the way we see her so much. But she comes
with a tremendous background in really the human service field
and now is representing the insurance company and is viewed as
one of the three trade associations.
Again, we welcome all views and we want everyone to really
lay it out, because what we're here to do is not debate, but to
discuss, to listen, to learn and to see how we can find that
sensible center the American people want us to.
We look forward to hearing from you all.
Mr. Guest.
STATEMENT OF JAMES GUEST, PRESIDENT AND CEO, CONSUMERS UNION,
YONKERS, NY
Mr. Guest. Well, Madam Chairwoman, thank you very much, and
members of the committee. I'm Jim Guest, President of Consumers
Union, publisher of Consumer Reports. Thank you for the chance
to be heard on this crucial issue.
Clearly, one of the most important pocketbook issues for
American families today is health care. For the last few years,
Consumer Reports has both done extensive surveys about the
health care crisis and we've also collected personal stories,
thousands of personal stories, many from women, about the
country's broken health care system.
Women are the chief purchasing officers in most households,
as you know, making health care decisions, buying decisions,
and managing the care of family members, as well as themselves.
But there is another reason that we hear from women so often
today and that's because the system makes accessing and
affording high quality care uniquely difficult and burdensome
for women. The reasons why--lower incomes, more part-time work,
more small businesses, more periods of unemployment to care for
children or aging parents, higher use of medical devices, and
so forth.
In September, just last month, Consumer Reports conducted
the latest of our nationally representative surveys and it
shows significant differences between men and women in the
impact of the health care crisis. Just to give a few numbers,
51 percent of all respondents said in the past year they had to
put off a doctor's visit, not fill a prescription, skip a
treatment, not pay a bill because of cost. But notably, women
were much more likely than men--55 percent for women compared
to 47 percent for men--to have faced those choices and given up
needed medical care.
Sixty-seven percent of women, compared to 59 percent of
men, fear they'll be denied coverage because of preexisting
conditions and other circumstances; and 78 percent of women,
versus 68 of men, fear they'll be unable to afford health care
in the future.
Behind those numbers, of course, are real people. From the
thousands of personal stories that we have gathered over the
years, it's clear that women far too often are not adequately
covered under current insurance practices. You members of the
committee have given many examples of that.
We have also heard from numerous women who found themselves
with coverage delayed or denied for some of the same causes
that were described here earlier. You can see some of the
stories, by the way, that we've collected in my written
testimony and in a reprint from Consumer Reports I'm happy to
make available.
The surveys and the personal stories highlight areas that
urgently need attention in the health care crisis. I just want
to flag three of them especially as they affect women. First is
the question of affordability, which is a major concern,
obviously, for everyone, for middle and lower income Americans,
and disproportionately for women. We support proposals
mentioned earlier that prohibit higher premiums due to gender
and we support limiting age rating to two to one.
We support expansion of Medicaid to the 133 percent poverty
level to provide a stable source of coverage for low-income
working women. We support the employer mandate to cover lower
wage workers, many of whom are women. And we support the
highest feasible--this is really important--the highest
feasible premium and cost-sharing assistance. On this, by the
way, we believe that the HELP bill is better, significantly
better, than the Finance version. And we support having a
public insurance plan option, which will expand consumer
choices, men and women, and hold down costs through greater
competition.
Second, on transparency, more complete, easy to use
information about medical providers and systems will enable
women, as the primary health shoppers, to make informed
choices. We like the HELP Committee scenarios, by the way, of
what it would cost to be treated for certain common conditions.
We support mandatory public disclosure of hospital-acquired
infections and other adverse events.
When it comes to insurance plans, it's most useful to give
not just what the premium's going to be, but the total cost of
a plan, rather than just the premium. That allows more informed
choices.
Then finally, I want to talk about the real importance of
the investment in comparative effectiveness research, which
will be a huge gain for women. It will help end the historic
underrepresentation of women in medical research that the
chairwoman referred to, and it holds the promise of medical
care that's more effectively tailored to subpopulations,
including subpopulations of women.
Finally, we vigorously support the HELP approach in terms
of comparative effectiveness research in a public agency, not a
private body. We think the advisory and oversight panels for
CERs should include a substantial number of consumer and
patient representatives, including women, as well as
independent experts, and we urge that there be a requirement
that all members of such panels be completely free of conflicts
of interest whatsoever.
Bottom line, Madam Chairwoman and members of the committee,
for women the health care crisis is very real, very personal,
and very scary. The time for action is now.
Thank you very much.
[The prepared statement of Mr. Guest follows:]
Prepared Statement of James Guest
Senator Mikulski and members of the committee, I'm Jim Guest,
President and CEO of Consumers Union, publisher of Consumer Reports,
and I thank you for the opportunity to testify on the subject of equal
treatment for women in our health care system. Consumers Union is a
non-profit, non-partisan, independent testing, research and public
policy organization whose mission is to work for a fair, safe and just
marketplace for all consumers. We have over 4 million subscribers to
our print magazine and more than 3.2 million on-line subscribers. We
have tested, reported and spoken out on health care matters since our
very first issue in February 1936.
For more than 70 years, we have been dedicated to helping consumers
make informed choices that affect their pocketbooks. And today, one of
the most important pocketbook issues for American families is health
care. For the past 2 years we have done extensive national surveys and
research which we have used in Consumer Reports articles to educate
consumers about what is happening in the health sector and the
underlying causes of today's health care crisis. In addition, we have
been collecting many thousands of personal stories from around the
country that illustrate the realities Americans are facing in our
broken health care system.
Several thousands of those who have shared their experiences with
us are women. Women are the ``chief purchasing officers'' in most
households--making most of the health-care buying decisions and
managing the health care of family members as well as their own. But
there is another reason we hear from so many women, and that is because
the system today makes accessing and affording high-quality health care
uniquely difficult and burdensome for women.
The reasons women are disproportionately impacted in the current
health care system are well documented: lower incomes, more part-time
work, more small businesses, more periods of unemployment to care for
children or aging parents, more bankruptcies, higher use of medical
services and so forth. The other experts on this panel can speak in
depth about these factors.
In September, the Consumer Reports National Research Center
conducted the latest of our nationally representative polls on health
care. Two sets of questions, in particular, showed significant
differences between men and women that are relevant to this panel's
focus today.
First, regarding cost and its impact on access to care, we asked
respondents if they were rationing their own care--that is, were they
restricting their use of health care due to cost. The results were
striking: 51 percent of all respondents said that in the past year they
had put off a doctor's visit, or not filled a prescription, or skipped
a treatment or procedure, or not been able to pay their medical bills
due to cost. Women were much more likely than men to face such
choices--55 percent to 47 percent.
Specifically, women are more likely to have:
Skipped filling a prescription (23 percent versus 16
percent).
Taken an expired medication (18 percent versus 11
percent).
Shared a prescription with someone else (12 percent versus
6 percent).
Second, we asked respondents about their main concerns regarding
health care. Women have greater concerns than men on most health care
issues, including significantly greater concern that they would:
Suffer a major financial loss or setback from medical cost
due to an illness or accident (77 percent versus 70 percent).
Face rising costs forcing a choice between healthcare and
other necessities (69 percent versus 59 percent).
Not be able to afford health care in the future (78
percent versus 68 percent).
Be denied health coverage because of preexisting
conditions or other circumstances (67 percent versus 59 percent).
And, by a difference of 75 to 70 percent, women are more concerned
that needed care will be rationed or denied by their insurance company.
In the thousands of stories we gathered in recent years of people's
experiences and concerns with the health care system, the reality is
clear: Common health needs specific to women too often are not covered
under current health insurance practices. We heard from numerous women
who found themselves with coverage delayed or denied because of very
common health needs such as benign fibroids, previous fertility
treatments, pregnancies and the like.
Attached are some truly moving stories that illustrate the types of
everyday problems women experience because of their unique health
needs.
These survey results and personal stories highlight policy areas
that need to be changed for all consumers of health care, but
especially for women. I want to highlight four such areas.
1. affordability
We support proposals that prohibit higher premiums due to gender.
These proposals will greatly help women, particularly in their young
adulthood.
We support limiting age-rating differentials. Doing so will help
women at an especially vulnerable time--the years leading up to
Medicare eligibility--when they often find themselves without their
husband's coverage due to divorce or death of their spouse. We
recommend the lowest age rating of 2:1, as in the House bills and the
Senate HELP Committee bill.
We support expansion of Medicaid to 133 percent of poverty ($24,400
for a family of 3) in order to provide a stable source of coverage for
low-income working women. We urge Congress to ensure that this
expansion be coupled with improvements in Medicaid provider rates so
that it increases real access to care, not just insurance.
Even with these important improvements, affordability remains a
major concern for middle- and lower-income people who are,
disproportionately, women. Because the costs of insurance are so high
relative to their families' take-home pay, all of the current bills
include sliding-scale subsidies to help them afford the insurance they
will be required to get under all of the proposals. We strongly believe
that more must be done to ensure affordability. We support the highest
possible premium subsidies that waive mandatory premiums for those on
Medicaid (those below 133 percent to 150 percent, or $24,400 to
$27,500, for a family of three) and charge families at 400 percent of
poverty ($73,240 for a family of three) no more than 10 percent of
their income. While this will increase costs, insurance reform will not
work effectively if it requires Americans to buy policies that are
unaffordable. Additional savings and progressive finances are needed to
ensure affordability.
Another problem is that in recent years consumers have seen more
and more of the costs of health care shifted to them in the form of
higher out-of-pocket cost-sharing, often at levels they cannot afford.
Therefore, we urge that you also limit out-of-pocket spending to no
more than 5 percent of income for people with incomes below 200 percent
of FPL and--using a graduated sliding scale--a limit between 5 percent
to 10 percent of income for people between 201 percent and 400 percent
of FPL. Finally, we support the approach taken by the HELP Committee to
increase the actuarial value of plans that are offered in order to
ensure that the coverage people will be required to carry will truly
protect against health care costs.
Finally, we strongly support giving American families the choice of
a Public Insurance Plan option, which will hold down costs by ensuring
competition and holding private insurers accountable.
2. coverage
All of the proposals under consideration make necessary and
important improvements in coverage for conditions that only women
experience--maternity and preventive services like mammograms and other
screenings. In addition, ending exclusions due to preexisting
conditions will help everyone, but as our stories show, this will
especially help increase women's access to affordable care without
penalty for common female conditions like fibroid tumors, C-sections
and other child-bearing-related experiences.
3. consumer information
Finally, I want to mention a third key reform that will help women
as the primary decisionmakers about health care in most families, and
that will greatly improve competition based on cost and quality,
helping reduce the growth of health costs over time.
Health care experts like to talk about the ``marketplace'' and
``competition.'' But today's health care marketplace lacks an essential
element necessary for consumers to be able to choose the insurance or
health care services that best meet their needs. People are forced to
make high-cost decisions without being able to know the full costs or
the relative quality and effectiveness of different insurance products,
procedures or providers. This has to change.
First, we all know about the fine print, loopholes, and ``got cha''
aspects of health insurance policies. It is vital that the final law
retains the HELP Committee provisions that define medical and insurance
terms so consumers can compare apples-to-apples. We particularly like
the HELP Committee's ``scenarios'' of what it would cost to be treated
for certain common conditions.
Second, in whatever ``exchange'' or ``connector'' marketplace that
is established to help people shop, make sure that the consumer is told
not just the premium cost, but also the estimated annual total cost,
based on past medical history or on one's own estimate of one's health
condition--for example, ``good health, fair health, poor health.''
Consumers Union has some data that shows that when consumers can see an
estimate of their likely total cost, they make much better choices than
if they only have premium information available. And if they make
better insurance choices, they will need less subsidy help with
premiums, deductibles, and co-pays. Total estimated cost data will help
everyone win.
Third, make available to consumers comparable information about the
quality and effectiveness of providers and different services. For
example, we support the Senate Finance provision that requires the
development of a rating system for plans based on relative quality and
price compared to other plans offering products in the same benefit
level. Consumers need this kind of help on the exchange Web sites to
deal with what is likely to be a confusing, busy new market (similar to
the 40-60 plans that faced seniors in Part C and D). As another
example, we also support Senator Reed's amendment in the HELP bill,
requiring clearer fact-based labeling of pharmaceuticals.
4. comparative effectiveness research (cer)
The CER provisions in the three bills will be a huge gain for women
in the decades to come. Women, and minorities, historically have been
badly under-represented in clinical trials and pharmaceutical and
medical device research. The new CER Trust Funds will provide a robust
level of funding that is mandated to give better, more balanced
attention to research on what works for women. CER holds the promise of
personalized medicine in the future, where, for example, the best
treatment for breast and other cancers can be determined by an
understanding of gene markers. We think it is crucial, however, that
CER research is housed in a public agency, as proposed by the HELP
Committee. Turning CER over to a private foundation means that the
process is likely to be captured by the medical industries, and instead
of delivering scientific research, it will become just another part of
the drug and device sales juggernaut. Further, members of the CER body
should be free of any personal or financial conflicts of interest, and
membership should include a substantial number of consumer and patient
representatives.
conclusion
The disproportionate burdens of the current system are unfair to
women. But in the end, the disparities have long-lasting effects on us
all, men as well as women. For men, these are our wives, our mothers,
our daughters, our sisters who are being denied the insurance coverage
and access to care that they deserve. When a mother or wife or daughter
or sister faces a serious health challenge, so does everyone in her
family. It is in the interests of all consumers that our health
insurance system must be improved. The time for action is now.
______
Examples of Why American Women Need Health Care Reform
dee k. from florida
During her first pregnancy, Dee suffered a miscarriage, a
devastating loss for her and her husband.
Sometime after that, Dee considered switching from her health plan
(purchased through the American Veterinary Medicine Association) to her
husband's non-group plan as the switch would save the family almost
$300 per month. Much to her surprise, and even the surprise of their
insurance agent, carriers in Florida refused to cover Dee due to her
miscarriage. In fact, they were told that Dee was considered
uninsurable for 5 years.
Dee was incredulous and angry: ``I am not a cancer patient. I am
healthy, don't smoke, and exercise. I do have back issues and dry eyes,
which I thought may cause more of a problem, but miscarriage is not a
constant state. At least 20 percent of women suffer miscarriage, and
probably many more go unreported.''
Unfortunately, Dee regrets obtaining medical care for her
miscarriage because now she must stay with her current policy which
features a $1,500 deductible and is not accepted by many physicians in
her area.
nanci l. from north carolina
During 1998, Nanci had a hysterectomy. Most of the surgery was paid
for by her non-group insurance policy. However, a year later her
insurers reversed their decision to cover Nanci's surgery. Why? Prior
to her surgery, Nanci's ob/gyn had written on her chart that her uterus
was fibrous, and the surgeon also found fibroids on her uterus during
the hysterectomy.
Her insurance carriers asserted these fibroids were a ``preexisting
condition'' and, hence, not covered under her policy. The carrier asked
the hospital and surgeon to return their payment and Nanci was
unexpectedly stuck with the bill for the hysterectomy--about $12,000.
The hospital that performed the surgery told Nanci, that if they didn't
return the payment, they would have trouble getting other claims paid.
This reversal is an industry practice called ``rescission.''
Exactly what is permitted will vary from State to State. In North
Carolina, a fibrous uterus can be considered a basis for denying
coverage, despite the fact that the condition is quite common among
women. As happened in Nanci's case, this denial can be made
retroactively leaving consumers vulnerable to large medical bills,
despite paying for insurance coverage.
tina g. from pennsylvania
Anticipating that she and her new husband would soon start a
family, Tina called her health insurance company to make sure she was
covered for maternity care. A customer service rep assured her that she
had maternity coverage and that she would only be responsible to pay
for 20 percent of all costs after the birth of the child. Four months
into her pregnancy, Tina started getting huge bills from the insurance
company.
Repeated phone calls finally revealed that she did not have
maternity coverage and that Tina would be responsible to pay for
everything. As Tina puts it ``[b]eing pregnant was stressful enough,
then to find out half way through the pregnancy that I didn't have the
proper coverage was even worse.'' Tina believes that the added stress
of huge, daunting medical bills contributed to high blood pressure
during her pregnancy and gestational diabetes--increasing the risk to
Tina's health and that of her unborn baby.
Tina contacted an attorney who suggested that she first try
contacting her local news channel's consumer reporter. This reporter
empathized with her plight and made some phone calls. As a result, the
reporter got insurers to admit that they incorrectly represented the
coverage during Tina's initial inquiries and convinced them to pay
Tina's maternity bills.
Tina, a registered nurse, advised people who interact with their
insurance company to document everything and to persist, using any
method available, if your health insurer appears to have made a
mistake.
stephanie h. from texas
Stephanie left the work force to care for her young child and left
behind the family's group health insurance policy she had through her
employer. Her husband is a self-employed professional without access to
group coverage. At the time, Stephanie was unconcerned because her
family (then ages 33, 35 and 2) was very healthy and not currently
taking any prescriptions.
When she applied for non-group family coverage she was shocked to
be turned down based on her usage of a drug called Clomiphene Citrate
over a 5-day period approximately 1 year earlier. Clomiphene Citrate is
a commonly used drug that stimulates ovulation. Stephanie notes it is
``the mildest fertility drug available'' and has a ``risk'' of less
than 10 percent of having twins. Stephanie complained and, with her
doctor, attempted to appeal the denial, but to no avail.
The stated reason for denial was that if she ever had another baby,
the insurer would be forced to cover the newborn even if it wasn't
healthy. Stephanie notes that rationale could be used to deny woman of
childbearing years. She also notes that she was not applying for
maternity health coverage and that her husband was also turned down for
this reason. Further, she already had one healthy child with no medical
complications. Stephanie contacted the Texas Department of Insurance as
well as Texas representatives about her plight, but also to no avail.
She was told that there was no remedy available within the current laws
and regulations.
Senator Mikulski. Well, thank you, and you even had 9
seconds to spare. That was great.
STATEMENT OF DIANA FURCHTGOTT-ROTH, SENIOR FELLOW, HUDSON
INSTITUTE, AND DIRECTOR, CENTER FOR EMPLOYMENT POLICY,
WASHINGTON, DC
Ms. Furchtgott-Roth. Madam Chairwoman, as a resident of the
State of Maryland, it's a great honor to testify in front of
you in this committee. Thank you very much for giving me the
opportunity.
I would like to say that our health insurance system is in
terrible shape. We never hear anybody say: ``Oh my goodness,
I'm losing my job, I'm losing my auto insurance.'' We never
hear anyone say: ``I'm losing my job, I'm losing my home
insurance.'' But we do hear: ``Oh my goodness, I'm losing my
job, I'm losing my health insurance.'' This is because of the
links between employment and health insurance.
We know how to do insurance. We don't have problems with
life insurance, auto insurance, home insurance. What we need to
do is give people a choice of health insurance plans, just as
the way we have for auto, home, and life insurance, just like
the Patients' Choice Act of Senator Burr and Senator Coburn,
who is a physician, that would give everyone the opportunity to
choose their own plans and have people, insurance companies,
competing for people's business, just like we see ads from
GEICO: Call us for a 15-minute quote and we'll give you a lower
rate. That's what we need to do with the health insurance
market.
Unfortunately, the bills in front of Congress right now,
the House Democrats' bill, the two bills in the Senate, are
anti-woman, anti-man, and anti-American. They would provide
worse care to all Americans. They would hurt our economy by
raising taxes, increasing our national debt, raising the
deficit. This would lower job creation and stop women from
progressing. Women progress when they are employed and right
now their unemployment rates are 2 percentage points lower than
men's. Women are doing well in this economy. But if they don't
have any jobs, they're not going to be doing well any more.
This bill would only help one group, foreign workers. They
would benefit from the outsourcing that American firms would do
to plants and firms by shipping jobs overseas. Foreign workers
are not the people we want to help. We want to help Americans.
There are four major things wrong with these bills. First
of all, everyone would pay more for health insurance because
the mandated plan that one would purchase under the health
exchange is so large that it would be very, very expensive. A
catastrophic bare-bones insurance plan, where you pay for
routine care, is not permitted under the health exchanges. You
would have to have no payments for routine care. A large array
of things would be covered, such as mental health, substance
abuse, that you might not need.
It's as though auto insurance paid for changing your
windscreen wiper blades and changing your oil. They're routine
expenditures that you can pay on your own. You don't need
insurance for that. Your auto insurance would be really
expensive if it paid for all those little things. But people
should be allowed to buy a plan that just has insurance against
major things, maybe having a baby, breaking a leg, getting hit
while you're on your bicycle, that kind of thing. But this plan
doesn't do it.
The higher cost of the premiums for this expensive plan
would lower cash wages, so lower income and minorities would be
more likely to lose their job. Say you have a job at minimum
wage, $7.25 right now. Your employer is required to cover you,
so in fact your wage couldn't go any lower. You would be
covered, but what would happen is the employer would have an
incentive not to hire you, just as when we raised the minimum
wage this summer the teen unemployment rate hit 26 percent
because these groups just were not hired any more.
Another problem with these bills is that those on Medicare
would receive worse care. As Senator Mikulski pointed out,
women are disproportionately large consumers of Medicare. But
these bills--the Baucus bill, for example, would cut $404
billion off Medicare with cuts in Medicare of 10 to 15 percent
every year. We're going to be covering more people, lower cost,
cuts in Medicare--no one can really believe that women are
going to continue to get the care, and men, that they get now
with these different cuts in Medicare, with such substantial
cuts.
In fact, Congress has overridden its own laws and not
allowed the 10 percent cuts in reimbursement rates for Medicare
physicians that have been in the law right now. It's overridden
those, but the bill mandates 25 percent cut in Medicare
reimbursement rates for physicians. Women aren't going to be
able to get to see their doctors.
Finally, health reform would discourage job creation and
incentive to work by raising taxes. House Democrats' bill, the
top rate would go to 45 percent, penalizing the most productive
small businesses, the most productive workers. They wouldn't
have an incentive to expand and create jobs.
It's also true at the low end. The Joint Tax Committee has
estimated that the effective tax rate for people at 150 percent
of the poverty line is 59 percent. They would face a tax of 59
percent because of the phaseout of the benefits. Those at 250
percent of the poverty line would face a tax rate of 49
percent. This is not something that we want to have. This bill,
we need health reform, but this is not the reform we have. We
need to take a serious look at Senator Burr's bill that would
give everyone tax credits to go out and buy their own plan,
just like we use our own money to go out and buy auto
insurance, life insurance, and home insurance.
Thank you very much.
[The prepared statement of Ms. Furchtgott-Roth follows:]
Prepared Statement of Diana Furchtgott-Roth
Senator Mikulski, Mr. Chairman, members of the committee, I am
honored to be invited to testify before your committee today on the
subject of the effects of the health reform bills on men and women. I
have followed and written about this and related issues for many years.
I am the coauthor of two books on women in the labor force, Women's
Figures: An Illustrated Guide to the Economic Progress of Women in
America, and The Feminist Dilemma: When Success Is Not Enough. I am
currently working on a sequel to Women's Figures, entitled Better
Women's Figures.
Currently I am a senior fellow at the Hudson Institute. From
February 2003 until April 2005 I was chief economist at the U.S.
Department of Labor. From 2001 until 2003 I served at the Council of
Economic Advisers as chief of staff and special adviser. Previously, I
was a resident fellow at the American Enterprise Institute.
Women are doing better than men in many measurable areas. Women
live on average 5.1 years longer than men.\1\ In September 2009, men's
unemployment rate was 11 percent and women's was 8.4 percent.\2\ Last
year women received 58 percent of all BA degrees awarded, and 61
percent of all MA degrees.\3\ Women have made tremendous progress in
labor force participation over the past 50 years: last year their labor
force participation was 14 percentage points lower than men's, compared
with 46 percentage points lower than men's in 1960.\4\ When
demographics, education, work experience, workplace and occupational
characteristics, and child-
related factors are taken into account, women earn practically the same
as men. In order to continue this progress, it is vital that American
employers be given the maximum opportunities to create jobs.
---------------------------------------------------------------------------
\1\ Jiaquan Xu, Kenneth D. Kochanek, and Betzaida Tejada-Vera,
``Deaths: Preliminary Data for 2007.'' Division of Vital Statistics,
National Vital Statistics Reports, Volt. 58, No. 1, August 19, 2009.
Available at http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_01.pdf.
\2\ Bureau of Labor Statistics, ``The Employment Situation--
September 2009,'' October 2009. Available at: http://www.bls.gov/
news.release/pdf/empsit.pdf.
\3\ U.S. Department of Education, National Center for Education
Statistics, ``Digest of Education Statistics: 2008,'' March 2009.
\4\ Bureau of Labor Statistics and Haver Analytics.
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Although the leading Democratic healthcare reform bills in
Congress--the Senate HELP Committee's Affordable Health Choices Act,\5\
the Senate Finance Committee's America's Healthy Future Act of 2009,\6\
and the House Education and Labor Committee's America's Affordable
Health Choices Act of 2009 \7\--intend to help women, they would leave
all Americans, including women, worse off than they are at present.
First, everyone, including women, would pay more for health insurance.
Second, the higher cost of health insurance premiums would lower cash
wages for Americans. Third, those on government plans, such as Medicare
and Medicaid, predominantly women, would receive worse care. Fourth,
the economy-wide effects of health care reform mandates would
discourage job creation and incentives to work by raising taxes.
---------------------------------------------------------------------------
\5\ U.S. Senate ``Affordable Health Choices Act.'' 111th Congress,
1st session. S. 1679. Washington: GPO, September 2009. Available at:
http://frwebgate.access.gpo.gov/cgi-bin/getdoc
.cgi?dbname=111_cong_bills&docid=-f:s1679pcs.txt.pdf.
\6\ U.S. Senate Committee on Finance, ``America's Healthy Future
Act of 2009.'' Available at: http://www.finance.senate.gov/sitepages/
leg/LEGpercent202009/100209_Americas_Healthy_
Future_Act_AMENDED.pdf.
\7\ U.S. House ``America's Affordable Health Choices Act of 2009.''
111th Congress, 1st session. H.R. 3200. Washington: GPO, July 2009.
Available at: http://frwebgate.access.gpo.gov/cgi-bin/
getdoc.cgi?dbname=111_cong_bills&docid=f:h3200ih.txt.pdf.
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Everyone, including women would pay more for health insurance.
Young women would have to pay substantially more for health insurance
than they do at present because premium differentials for health
insurance would be capped. All women would have to pay more due to the
government's definition of a qualified plan.
One feature of the health reform bills is that variation in
premiums would be limited. Under the House Democrats' bill, for
example, the most expensive premium could not be more than twice as
much as the cheapest for the same plan, and variation would only be
allowed on the basis of age. This means that younger women would have
to pay far more in premiums than they would otherwise.
The Baucus bill would require everyone to purchase health insurance
or face penalties. Americans with incomes up to 400 percent of the
poverty line (currently $90,100 for a family of four) who are not
covered by an employer plan would receive tax credits to purchase
health insurance plans in an ``exchange.''
Plans purchased in the exchange would be Cadillac plans, with
generous coverage and no lifetime or annual limits on any benefits.
Only Americans under 25 and those who spend more than 8 percent of
their income on health insurance premiums would be allowed to purchase
``young invincible'' plans, catastrophic insurance against major
accidents. American men and women would have to pay a far higher cost
for health insurance, since plans would have to accept everyone,
regardless of health or pre-existing conditions.
It's easy to see from the Baucus bill why the cost of health
insurance is going to skyrocket. According to the Senate Finance
Committee, ``All plans would be required to provide primary care and
first-dollar coverage for preventive services, emergency services,
medical and surgical care, physician services, hospitalization,
outpatient services, day surgery and related anesthesia, diagnostic
imaging and screenings, including x-rays, maternity and newborn care,
pediatric services (including dental and vision care), prescription
drugs, radiation and chemotherapy, and mental health and substance
abuse services. Plans would not be allowed to set lifetime limits on
coverage or annual limits on any benefits.'' \8\
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\8\ U.S. Senate Committee on Finance, ``Baucus Introduces Landmark
Plan to Lower Health Care Costs, Provide Quality, Affordable Coverage''
(News Release) September 16, 2009. Available at: http://
finance.senate.gov/press/Bpress/2009press/prb091609h.pdf.
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Half of the Baucus plan would be funded through an excise tax on
expensive plans of 40 percent on premiums above $8,000 for singles and
$21,000 for families, bringing in $201 billion from 2013 through 2019.
Today health insurance premiums cost on average $4,824 for singles and
$13,375 for families.\9\ CBO's calculates that in 2019, in addition to
$46 billion in excise taxes, Americans would be paving over $100
billion in higher premiums.\10\ Since CBO forecasts increases in excise
tax revenues of 10 percent to 15 percent annually after 2019, health
insurance premiums must also rise by the same percent annually. This
government mandate will amount to a steady drain on American men and
women. A memo dated October 13, 2009, from Thomas Barthold, chief of
staff of the Joint Committee on Taxation, said ``Generally, we expect
the insurer to pass along the cost of the excise tax to consumers by
increasing the price of health coverage.'' \11\
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\9\ The Kaiser Family Foundation and Health Research and
Educational Trust, ``Employer Health Benefits 2009 Annual Survey''
September 15, 2009. Available at: http://egbs.kff.org/pdf/2009/
7936.pdf.
\10\ Congressional Budget Office. ``Letter to the Honorable Max
Baucus on the Preliminary Analysis of the Chairman's Mark for the
America's Healthy Future Act, as Amended,'' October 7, 2009. Available
at: http://www.cbo.gov/ftpdocs/106xx/doc10642/10-7-Baucus_letter.pdf.
\11\ Joint Committee on Taxation. ``Memo from Thomas A. Barthold to
Cathy Koch and Mark Prater,'' October 13, 2009.
---------------------------------------------------------------------------
The higher cost of health insurance premiums would lower cash wages
for everyone, in particular women. A government mandate for employers
to provide health insurance would cause wages to decline, because the
costs of the insurance would be passed on to workers, who would see a
decline in wages. Alternatively, discussed in the following section,
employers would reduce employment, especially for low-wage workers.
Harvard University economics professor Katherine Baicker and
University of Michigan economics professor Helen Levy concluded that
low-income, minority workers would be the most affected by a government
mandate: \12\ ``We find that 33 percent of uninsured workers earn
within $3 of the minimum wage, putting them at risk of unemployment if
their employers were required to offer insurance. . . . Workers who
would lose their jobs are disproportionately likely to be high school
dropouts, minority, and female. Thus, among the uninsured, those with
the least education face the highest risk of losing their jobs under
employer mandates.''
---------------------------------------------------------------------------
\12\ Katherine Baicker and Helen Levy, ``Employer Health Insurance
Mandates and the Risk of Unemployment,'' NBER Working Paper No. 13528,
October 2007. Available at: http://www.nber.org/papers/W13528.pdf.
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Employers are likely to respond to the higher costs resulting from
mandated provision of health insurance by employing fewer workers, or
outsourcing jobs overseas. This would be especially harmful for small
businesses which employ low-income wage workers at or near the minimum
wage since employers cannot reduce these wages to absorb the increased
cost. It is no coincidence that this summer's increase in the minimum
wage to $7.25 hourly \13\ was followed by record teen unemployment
rates, the latest almost 26 percent in September.\14\ Employers laid
off the less-skilled workers rather than paying them more than they
were worth.
---------------------------------------------------------------------------
\13\ U.S. Department of Labor Wage and Hour Division, ``Employee
Rights under the Fair Labor Standards Act,'' July 2009. Available at:
http://www.dol.gov/esa/whd/regs/compliance/posters/minwagep.pdf.
\14\ Bureau of Labor Statistics, `` The Employment Situation--
September 2009.''
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CBO concluded that a requirement for employers to provide health
insurance would encourage employers to hire more part-time workers and
fewer full-time workers. According to CBO, the creation of different
penalties for full- and part-time workers ``would increase incentives
for firms to replace full-time employees with more part-time or
temporary workers.'' \15\
---------------------------------------------------------------------------
\15\ Congressional Budget Office, ``Effects of Changes to the
Health Insurance System on Labor Markets,'' July 13, 2009. Available
at: http://www.cbo.gov/ftpdocs/104xx/doc10435/07-13-
HealthCareAndLaborMarkets.pdf.
---------------------------------------------------------------------------
According to Ezekiel Emanuel and Victor Fuchs in the Journal of the
American Medical Association,
``It is essential for Americans to understand that while it
looks like they can have a free lunch--having someone else pay
for health insurance --they cannot. The money comes from their
own pockets. Understanding this is essential for any
sustainable health care reform.'' \16\
---------------------------------------------------------------------------
\16\ Ezekiel J. Emanuel and Victor R. Fuchs, ``Who Really Pays for
Health Care Costs,'' Journal of the American Medical Association, March
5, 2008. Similarly, Harvard economist Katherine Baicker wrote,
``Employees ultimately pay for the health insurance they get through
their employer, no matter who writes the check to the insurance
company. The view that we can get employers to shoulder the cost of
providing health insurance stems from the misconception that employers
pay for benefits out of a reservoir of profits. Regardless of a firm's
profits, valued benefits are paid for primarily out of workers'
wages.'' Katherine Baicker and Amitabh Chandra, ``Myths and
Misconceptions about U.S. Health Insurance,'' Health Affairs, 2008.
---------------------------------------------------------------------------
Peter Orszag reiterated this as CBO director, saying that,
``The economic evidence is overwhelming, the theory is
overwhelming, that when your firm pays for your health
insurance you actually pay through reduced take-home pay. The
firm is not giving that to you for free. Your other wages or
what have you are reduced as a result. I don't think most
workers realize that.'' \17\
---------------------------------------------------------------------------
\17\ CBO Director Peter Orszag Testimony before the Senate Finance
Committee, June 17, 2008.
---------------------------------------------------------------------------
Those on government plans, such as Medicare and Medicaid,
predominantly women, would receive worse care. Medicare recipients, who
are primarily women,\18\ would receive a lower standard of care than
they do at present due to cuts in the program. Putting more low-income
women into the Medicaid program would give them a lower standard of
care.
---------------------------------------------------------------------------
\18\ The Kaiser Family Foundation, ``Medicare's Role for Women,''
June 2009. Available at: http://www.kfforg/womenshealth/upload/
7913.pdf.
---------------------------------------------------------------------------
Nearly 90 percent of the $404 billion Medicare and Medicaid savings
would be from Medicare in the period 2013 to 2019 in the Baucus bill.
Thereafter, savings would be expected to continue at the rate of 10
percent to 15 percent. Of all demographic groups in America, elderly
women would be the biggest losers under the Baucus plan. CBO estimates
that Medicare Advantage plans, popular bundled health maintenance
organizations serving 20 percent of Medicare patients, primarily women,
would be cut by $117 billion.\19\ Under the heading ``Ensuring Medicare
Sustainability,'' more than $200 billion would be cut from payments to
hospitals, elder care, doctors, and hospices. Payments to Medicare
doctors would be cut by 25 percent in 2011. A Medicare Commission would
propose further cuts.
---------------------------------------------------------------------------
\19\ Congressional Budget Office. ``Letter to the Honorable Max
Baucus on the Preliminary Analysis of the Chairman's Mark for the
America's Healthy Future Act, as Amended.''
---------------------------------------------------------------------------
The government would persuade doctors to cut Medicare costs by
associating more tests with lower reimbursements. Ranked in order of
spending per patient, every year the top 10 percent of physicians would
have their reimbursements cut. Since by definition there would always
be 10 percent of physicians in the top 10 percent, they would have an
incentive to avoid the sickest patients or the specialties with the
most tests. Since women are disproportionate users of Medicare, they
would be the most affected.
According to the Kaiser Family Foundation, women comprise 69
percent of Medicaid recipients.\20\ The House Democrats bill plans to
expand the Medicaid program to 133 percent of the poverty line in order
to cover low-income uninsured workers. Not only would this cause a
financial drain on already-strained budgets, but Medicaid does not
provide as high a level of care as with many other private plans. Women
would be disadvantaged by being put on Medicaid rather than being given
a refundable tax credit to purchase a private plan, as has been
suggested by Congressman Tom Price.
---------------------------------------------------------------------------
\20\ The Kaiser Family Foundation, ``Medicaid's Role for Women,''
October 2007. Available at: http://www.kff.org/womenshealth/upload/
7213_03.pdf.
---------------------------------------------------------------------------
Many Medicaid patients cannot find doctors who will see them. In
California, 49 percent of family physicians do not participate in
Medicaid \21\ while in Michigan the number of doctors who do not see
Medicaid patients has risen from 12 percent in 1999 to 36 percent in
2005.\22\ Physicians don't want to take Medicaid patients because of
low reimbursement and substantial paperwork. A 2009 Health Affairs
report indicated that Medicaid physician fees increased 15.1 percent,
on average, between 2003 and 2008.\23\ This was below the general rate
of inflation of 20.3 percent, resulting in a reduction in real fees.
---------------------------------------------------------------------------
\21\ Lisa Backus et al., ``Specialists' and Primary Care
Physicians' Participation in Medicaid Managed Care,'' Journal of
General Internal Medicine, Volt. 16, No. 12. December 2001.
\22\ Jay Greene, ``Committee looks at taxing Michigan doctors to
help avert 12 percent Medicaid cuts,'' Michigan State Medical Society,
September 22, 2009. Available at: http://www.msms.org/AM/
Template.cfm?Section = Advocacy &TEMPLATE =/CM/
ContentDisplay.cfm&CONTENTID=
12302.
\23\ Stephen Zuckerman, Aimee F. Williams, and Karen E. Stockley,
``Trends in Medicaid Physician Fees, 2003-2008,'' Health Affairs, Volt.
28, No. 3, 2009.
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The economy-wide effects of health care reform mandates would
discourage job creation and incentives to work by raising taxes. The
tax increases in the House bill would disproportionately fall on women,
discourage job creation, and reduce the incentives for married women to
work.
According to Dr. Jonathan Javitt, adjunct professor of public
health at Johns Hopkins University,
``Many more women are single parent heads of households than
are men. If families are taxed for not having health insurance,
this tax is certain to disproportionately penalize single-
parent families who are barely making ends meet.''
Health reform is expensive, and some of the bills pay for it
through increased taxes. For instance, the House bill relies on income
tax surcharges on the most productive workers, bringing the top tax
rate to 45 percent, as well as an 8 percent payroll tax on employers
who do not offer the right kind of health insurance to their employees.
Moreover, anyone who does not sign up for health insurance would face
an additional 2.5 percent income tax. Taxes discourage work and
investment, thereby reducing employment.
Such tax increases would adversely affect married women because
their incomes are frequently secondary. It would not only discourage
marriage, but also discourage married women from working.
By raising taxes on upper-income Americans to 45 percent, Congress
would worsen our tax system's marriage penalty on two-earner married
couples, and women would pay even more tax married than single. Unless,
of course, women left the workforce, lowering a couple's Federal tax
rate. Federal taxes are not the whole story. State taxes would take
another 9 percent of incomes in States such as Oregon, Vermont and
Iowa; Medicare would take another 1.45 percent; and Social Security
taxes would add another 6.2 percent up to $107,000.
The tax penalty for working is even more substantial at the low end
of the income spectrum. The staff of the Joint Tax Committee estimated
that combined effective income and premium marginal tax rates,
including payroll taxes, for poor families of four under the Baucus
bill would be substantial, dwarfing rates for upper-income individuals.
They would reach 59 percent at 150 percent of the poverty line; 49
percent at 250 percent of the poverty line; 39 percent at 350 percent
of the poverty line; and 40 percent at 450 percent of the poverty
line.\24\
---------------------------------------------------------------------------
\24\ Joint Committee on Taxation. ``Memo from Thomas A. Barthold to
Mark Prater, Tony Coughlan, Nick Wyatt, and Chris Conlin'' October 13,
2009.
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When mothers take jobs, earnings are reduced by taxes, in addition
to costs for childcare and transportation. This discourages women not
just from working, but also from striving for promotions, from pursuing
upwardly-mobile careers. Mothers are more affected by the marriage
penalty than other women because they are more likely to move out of
the labor force to look after newborn children and toddlers, and then
to return to work when their children are in school.
Our tax system should not make it harder for women to work. The
penalty falls both on women struggling to escape from poverty, and on
married women who have invested in education, hoping to shatter glass
ceilings and compete with men for managerial jobs. Throughout the
income spectrum, higher taxes would exacerbate the penalty for working.
Our health insurance system needs to change, but not in the way
envisaged by Congress. Rather than mandating one expensive plan,
Congress would do better to change the current health insurance tax
credit from employers to individuals and allow people to pick their own
portable plans, as they do with other forms of insurance. That would
help women, and men too. It is vital that women's progress in the labor
force continue, and the main route to this progress is an abundant
supply of job opportunities. As configured, the three plans under
consideration today would impede such job creation.
Thank you for allowing me to appear before you today. I would be
glad to answer any questions.
Reference
Bureau of Labor Statistics, ``The Employment Situation--September
2009,'' October 2009. Available at: http://www.bls.gov/
news.release/pdf/empsit.pdf.
Congressional Budget Office, ``Effects of Changes to the Health
Insurance System on Labor Markets,'' July 13, 2009. Available at:
http:/www.cbo.gov/ftpdocs/104xxdoc10435/07-13-
HealthCareAndLaborMarkets.pdf.
Congressional Budget Office. ``Letter to the Honorable Max Baucus on
the Preliminary Analysis of the Chairman's Mark for the America's
Healthy Future Act, as Amended,'' October 7, 2009. Available at:
http://www.cbo.gov/ftpdocs/106xx/doc10642/10-7-Baucus_letter.pdf.
CBO Director Peter Orszag, Testimony before the Senate Finance
Committee, June 17, 2008.
Ezekiel J. Emanuel, MD, PhD and Victor R. Fuchs, PhD, ``Who Really Pays
for Health Care Costs,'' Journal of the American Medical
Association, March 5, 2008.
Jay Greene, ``Committee looks at taxing Michigan doctors to help avert
12 percent Medicaid cuts,'' Michigan State Medical Society,
September 22, 2009. Available at: http:/www.msms.org/AM/
Template.cfm?Section=Advocacy&TEMPLATE=/CM/
ContentDisplay.cfm&CONTENTID=12302.
Jiaquan Xu, Kenneth D. Kochanek, and Betzaida Tejada-Vera, ``Deaths:
Preliminary Data for 2007.'' Division of Vital Statistics, National
Vital Statistics Reports, Volt. 58, No. 1, August 19, 2009.
Available at http://www.cdc.gov/nchs/data/nvsr/nvsr58/
nvsr58_01.pdf.
Katherine Baicker and Amitabh Chandra, ``Myths and Misconceptions about
U.S. Health Insurance,'' Health Affairs, 2008).
Katherine Baicker and Helen Levy, ``Employer Health Insurance Mandates
and the Risk of Unemployment,'' NBER Working Paper No. 13528,
October 2007. Available at: http://www.nber.org/papers/w13528.pdf.
Lisa Backus, et al., ``Specialists' and Primary Care Physicians'
Participation in Medicaid Managed Care,'' Journal of General
Internal Medicine, Volt. 16, No. 12. December 2001.
Stephen Zuckerman, Aimee F. Williams, and Karen E. Stockley, ``Trends
in Medicaid Physician Fees, 2003-2008'', Health Affairs, Volt. 28,
No. 3, 2009.
The Kaiser Family Foundation, ``Medicaid's Role for Women,'' October
2007. Available at: http://www.kff.org/womenshealth/upload/
7213_03.pdf.
The Kaiser Family Foundation, ``Medicare's Role for Women,'' June 2009.
Available at: http://www.kff.org/womenshealth/upload/7913.pdf.
The Kaiser Family Foundation and Health Research and Educational Trust,
``Employer Health Benefits 2009 Annual Survey'' September 15, 2009.
Available at: http://ehbs.kff.org/pdf/2009/7936.pdf.
U.S. Department of Education, National Center for Education Statistics,
``Digest of Education Statistics: 2008,'' March 2009.
U.S. Department of Labor Wage and Hour Division, ``Employee Rights
under the Fair Labor Standards Act,'' July 2009. Available at:
http:/www.dol.gov/esa/whd/regs/compliance/posters/minwagep.pdf.
U.S. Senate ``Affordable Health Choices Act.'' 111th Congress, 1st
session. S. 1679. Washington: GPO, September 2009. Available at:
http://frwebgate.access.gpo.gov/cgi-bin/
getdoc.cgi?dbname=111_cong_bills&docid=f:s1679pcs.txt.pdf.
U.S. Senate Committee on Finance, ``America's Healthy Future Act of
2009.'' Available at: http:/www.finance.senate.gov/sitepages/leg/
LEGpercent202009/100209_
Americas_Healthy_Future_ActAMENDED.pdf.
U.S. Senate Committee on Finance, ``Baucus Introduces Landmark Plan to
Lower Health Care Costs, Provide Quality, Affordable Coverage''
(News Release) September 16, 2009. Available at: http://
finance.senate.gov/press/Bpress/2009press/prb091609h.pdf.
U.S. House ``America's Affordable Health Choices Act of 2009.'' 111th
Congress, 1st session. H.R. 3200. Washington: GPO, July 2009.
Available at: http://frwebgate
.access.gpo.gov/cgi-bin/
getdoc.cgi?dbname=111_cong_bills&docid=f:h3200ih.txt
.pdf.
Senator Mikulski. Ms. Crouse.
STATEMENT OF JANICE SHAW CROUSE, Ph.D. DIRECTOR AND SENIOR
FELLOW, CONCERNED WOMEN FOR AMERICA, WASHINGTON, DC
Ms. Crouse. Thank you. I'm from Maryland, too, Senator
Mikulski. It's a privilege to present testimony before this
august group on such an important topic and to participate in a
debate on an issue that is so important to the future of this
Nation.
Let me assure you that I agree with the wonderful arguments
that have been put forth about the importance of the equality
of care--health care--for women. I represent Concerned Women
for America, the Nation's largest public policy women's
organization. We are a membership group with over 600,000
members from all across the United States. Our grassroots
members are women on the Main Streets of small town America and
big city America. We are the women who will be most affected by
health care reform provisions, those things that are being
discussed.
You can read my formal testimony. Copies are on the table
and all of the members have received copies. But in my verbal
remarks this morning I want to focus on two issues that are
vitally concerning to the women that I represent. Those two
issues are the elephant in the room this morning when it comes
to women's concerns, and that is abortion and end of life
women's issues.
In the Old Testament, the Fifth Commandment is given with a
promise. We are told that we should honor our father and
mother, and if we do we will live long lives. No Nation can
hope to prosper if it does not act in accordance with this
mandate. To claim that cutting Medicare by half a trillion
dollars will have no impact on senior citizen benefits mocks
voters and insults our intelligence. No amount of smoke and
mirrors can conceal this fact from our Nation's senior
citizens, and most of our senior citizens are women. Many of
them, if not most of them, have been mothers.
These mothers are the backbone of our Nation. They are the
very DNA. The DNA of a mother is a mandate to answer the call
to sit in vigil with a sick child or any loved one who is sick.
Mothers generally do not begrudge that labor and service to
those that they love.
It's an outrage when we hear politicians say to these
mothers that as old women their years of service are ended and
it's time for them to quit consuming resources. In a democratic
representative democracy, elected officials are honor-bound to
represent those whom they serve.
A November 2008 Zogby poll revealed 71 percent of Americans
oppose government-funded abortion. Those of us who give
testimony and represent the public are free citizens, very
grateful for the opportunity to give feedback and opinion on
the issues before this great body of legislators. But in a
representative democracy we are not summoned by masters and we
are not intimidated by power. Instead, we are here representing
the views of thousands, if not millions, just like us, who do
not intend for our voices to be unheard or our choices limited
or for our hard-fought liberties to be taken away by those who
would obfuscate, distort, or hide the truth.
No one today here should forget that the citizenry of this
Nation has a history of overthrowing tyranny, and nothing is a
clearer act of tyranny than for Congress to legislate change
that abrogates our God-given right to choose life.
It is clear that the current health care reform legislation
would classify abortion as an essential benefit and make it
illegal for health care workers to deny abortion to anyone who
seeks it, regardless of their personal convictions or their
beliefs. Further, it is clear that the legislation would
overrule State laws that require limitations, such as mandatory
parental notification or even waiting periods.
It is also clear that the current bills would force
American citizens, whether they want to or not, to subsidize
abortion on demand with their tax dollars. Even those with
incomes up to 400 percent of poverty would receive subsidies to
pay for abortions.
Many things are negotiable and amendable to finding some
middle ground, but human life is sacred. Its defense is not
open to negotiation or to compromise. Defending life is our
sacred duty.
The 6,000 women of CWA and the millions of like-minded
women in this country count it a privilege to stand for those
who are too vulnerable to stand for themselves.
Thank you for this opportunity.
[The prepared statement of Ms. Crouse follows:]
Prepared Statement of Janice Shaw Crouse, Ph.D.
summary
While the cost is a major concern, health care reform must respect
all life, at the beginning and end of life.
issues related to abortion
We have two primary concerns about health care reform relating to
abortion--whether it funds and covers abortion and whether it allows
health care workers freedom of conscience.
Funding and Covering Abortion: Without explicit wording prohibiting
abortion funding and coverage, health care reform will involve all
American taxpayers in explicit financial support for abortion-on-
demand. In addition, Planned Parenthood is a ``community provider''
under health care reform bills.
Freedom of Conscience for Health Care Workers: Any health care
reform provisions must provide protection for the rights of conscience
for health care workers and medical providers. Those whose faith or
conscience prevent them from performing abortions must have the ability
to object and refrain from participating in actions that are contrary
to their beliefs.
issues related to end-of-life
Life Sustaining Treatment: Pro-lifers are, rightly, concerned about
the possibility of limitations on life-sustaining treatment of the
elderly, permanently disabled, terminally ill, or those with long-term
chronic illnesses. No one should suggest the least expensive treatment
or no treatment for those who are at or near the end of life or those
whose conditions are irreversible.
Care at the End-of-Life: One of the most troubling aspects of
health care reform legislation concerns end-of-life issues. Any health
care reform must provide effective treatment for the Nation's older
people--without curtailment, withdrawal or denial of life-sustaining
care for the terminally ill, the chronically ill, or the permanently
disabled. Further, those provisions that address end-of-life issues
must clearly leave no room for an interpretation that would pressure
healthcare providers to make decisions based on cost rather than the
best medical care.
conclusion
Concerned Women for America believes that for any health care
legislation to pass Congress it must protect life from conception to
death. Therefore, we recommend:
1. First and foremost, abortion must be explicitly prohibited both
in funding and coverage, with the Hyde Amendment permanently codified
in law.
2. Second, the right to free exercise of their conscience must be
granted to all health care workers without penalty or intimidation.
3. Third, life-sustaining treatment must be available to all
citizens, including the elderly, terminally or chronically ill or those
who are permanently disabled.
4. Fourth, we categorically reject end-of-life counseling based on
cost considerations and government formulas generated by Comparative
Effectiveness Research. And, we reject all assisted suicide measures.
______
It is a pleasure to address this distinguished committee and to be
a part of this distinguished panel. We are part of one of the most
important debates to face this Nation--especially for women and
children. Ironically, as this debate rages, my book, Children at Risk,
is being printed by the publisher. That book details all the ways that
we are failing our children--primarily because of fatherless families
leaving both women and children to face the vicissitudes of life
without the support, protection and comfort that they need to thrive.
With the additional costs and the problems associated with the health
care reform bills currently in Congress, the burdens on women and
children will escalate.
There is ample evidence (including a just-released report from
Pricewater-
houseCoopers) that health care reform measures will be prohibitively
expensive--more than twice the expected growth in the Consumer Price
Index with the increased cost of health insurance premiums being borne
by individuals and families.\1\
---------------------------------------------------------------------------
\1\ ``Potential Impact of Health Reform on the Cost of Private
Health Insurance Coverage,'' PricewaterhouseCoopers, October, 2009.
---------------------------------------------------------------------------
While the cost is a major concern, I would like to focus this
morning on health care concerns at the beginning and end of life.
Health care reform must respect all life, but human beings are
especially vulnerable at the beginning and end of their lives.
Provisions of a satisfactory plan must protect the baby in the womb and
provide effective care for citizens at the end of life. At both these
stages of life, females are more vulnerable than males.
issues related to abortion
We have two primary concerns about health care reform relating to
abortion--whether it funds and covers abortion and whether it allows
health care workers freedom of conscience.
Funding and Covering Abortion: In spite of all the rhetoric to the
contrary, all the health care reform bills currently before Congress
mandate abortion funding and coverage. As pointed out so effectively by
Americans United for Life (AUL), all of the pro-life amendments that
came before the various committees were rejected. It is very clear that
any health care reform bill must contain express language prohibiting
abortion funding and coverage. Otherwise, ``courts and administrative
agencies will interpret health care reform to include it, based on
prior interpretations of Medicaid's `Mandatory Categories of Care.' In
addition, the Hyde Amendment, as added yearly to HHS Appropriations, is
insufficient to prevent abortion funding and coverage under the health
care bills.'' \2\ In short, without explicit wording prohibiting
abortion funding and coverage, health care reform will involve all
American taxpayers in explicit financial support for abortion-on-
demand.
---------------------------------------------------------------------------
\2\ Mary Harned, ``A Pro-Life Look at the Health Care Reform Bills
Currently in Congress,'' Americans United for Life, October 12, 2009,
p. 1. http://blog.aul.org/2009/10/10/a-pro-life-look-at-the-health-
care-reform-bills-currently-in-congress/.
---------------------------------------------------------------------------
For instance, the Senate HELP bill provides for a ``Medical
Advisory Committee'' (Sec. 3103) to determine the specific benefits
that are offered by the private and public health care plans. The
members of this committee (to be appointed by President Obama's
administration rather than be elected or result from a Senate-
appointed bipartisan effort) will make decisions regarding whether
abortion will be mandatory in the health care plans that are offered.
President Obama has made it clear that he supports such coverage.
Indeed, in July 2007 speech he promised Planned Parenthood that his
Administration would provide mandatory abortion coverage.
In addition, Planned Parenthood is a ``community provider'' that
would be included in the health insurance networks under health care
reform bills. Under Sen. Mikulski's (D-MD) amendment, accepted by the
Senate HELP committee, community providers ``that serve predominantly
low-income, medically under-served individuals'' would be covered to
provide ``any service deemed medically necessary or medically
appropriate.'' At the time that her amendment passed, Sen. Mikulski
pointedly refused Senator Hatch's request to specifically exclude
``abortion services.''
In the Senate HELP Committee, four separate pro-life amendments
were defeated along party lines, with the notable exception of Sen. Bob
Casey (D-PA) who consistently votes pro-life. The amendments would have
prevented taxpayer funding for abortion, excluded abortion clinics from
Federal grants and would have kept health care plans from including
provisions to invalidate State laws regulating abortion. Obviously, the
defeat of these amendments indicates the intent to implement by stealth
what cannot be openly passed by vote. Lest anyone think such statements
are an exaggeration, the lawyers at Americans United for Life have
itemized cases where the courts have interpreted ``Mandatory
Categories'' of care to include abortion.\3\ AUL notes that though
abortion is not explicitly named as a service, the courts have
concluded that abortion is included in ``family planning,''
``outpatient services,'' ``inpatient services'' and ``physician
services.''
---------------------------------------------------------------------------
\3\ http://www.aul.org/.
---------------------------------------------------------------------------
In seeking to reassure pro-life citizens, supporters of health care
reform measures always refer to the Hyde Amendment as protecting the
pro-life cause. Sadly, the Hyde Amendment, which prohibits taxpayer
money for abortion through the Medicaid program, is not permanent law,
instead, it is a pro-life rider that must be re-introduced and passed
annually. Further, the proposed health care reform measures include
funding mechanisms that enable Congress to circumvent the Hyde
Amendment. This ``back door spending authority'' completely bypasses
the Appropriations Committee. In addition, the tax credit provisions of
the Baucus bill are not dependent upon the annual appropriations
process so Hyde doesn't apply there, either.
Freedom of Conscience for Health Care Workers: Any health care
reform provisions must provide protection for the rights of conscience
for health care workers and medical providers. Those whose faith or
conscience prevent them from performing abortions must have the ability
to object and refrain from participating in actions that are contrary
to their beliefs. The Kennedy amendment [the late Sen. Ted Kennedy (D-
MA)--(amdt. 205) is often invoked to reassure pro-lifers that health
care workers will continue to be free to object to participate in
performing abortions. The Kennedy amendment, however, has limited
scope: it does not cover those who refuse to pay for or to refer
patients for abortion services. Further, the Kennedy amendment has a
provision for an exception in ``cases of emergency''--an undefined
phrase allowing for broad interpretation.\4\ Again, an amendment--
(amdt. 246) to specifically allow health care providers to refuse to
participate in an abortion or to be discriminated against when they do
so--failed, clear evidence of the intent of those who are pushing for
health care reform measures with vague references and back door
mechanisms. The American people deserve--and demand--clarity on any
measures that are brought to vote and passed into law.
---------------------------------------------------------------------------
\4\ The Congressional Budget Office sent a devastating analysis of
the provisions to Senator Kennedy in a letter dated July 2, 2009 with
two attachments. Their analysis indicated ``a net increase in Federal
budget deficits of $597 billion over the 2010-2019 period--reflecting
net costs of $645 billion for the coverage provisions which would be
partially offset by net savings of $48 billion from other provisions in
title I. (CBO has also estimated the budgetary impact of provisions in
titles III and VI of an earlier draft of the legislation, which would
add another $14 billion to the net cost of the proposal.'' They
estimated very little change in the number of people covered by
insurance.
---------------------------------------------------------------------------
issues related to end-of-life
Life Sustaining Treatment: Pro-lifers are, rightly, concerned about
the possibility of limitations on life-sustaining treatment of the
elderly, permanently disabled, terminally ill, or those with long-term
chronic illnesses. All the health care reform measures currently under
consideration utilize the CER, Comparative Effective Research, a
technique that compares and measures the benefits and harms of
treatments, including prevention, diagnosis, treatment, and monitoring
of health care delivery services. There are legitimate concerns that
the CER will be used to determine whether to come to the aid of those
who are elderly, terminally or chronically ill or those who are
permanently disabled. Certainly, high profile politicians have made
comments that would indicate they believe the least expensive treatment
or no treatment at all is appropriate for those who are at or near the
end of life or those whose conditions are irreversible.
Currently, the Senate HELP bill contains a comparative
effectiveness provision--the Center for Health Outcomes Research and
Evaluation (CHORE)--but the CHORE is charged to ``report and
recommend'' rather than to ``mandate.'' Nothing in the bill, however,
keeps it from being used to deny treatment. Further, the bill provides
incentives for health care providers to use cost-effective measures.
(See Sec. 2707 (1)(C)). Most troubling, the bill establishes a Medical
Advisory Council, reporting to the Secretary of Health and Human
Services, to establish a minimum set of required ``health care
benefits.''
It must be noted that, as is true with the other pro-life
amendments, all amendments (amdts. 278 and 280) to prohibit cost-driven
``curtailment, withdrawal or denial'' of care and those that would
prevent rationing or forcing taxpayers to fund assisted suicide (amdts.
232, 233, 228) were rejected along party line votes. Amazingly,
amendments ensuring that everyone have access to essential health
benefits regardless of their age, expected length of life or disability
(amdts. 209, 210, and 211)--even amendments preventing private health
insurers from being prevented from covering treatments--were defeated
along party lines.
Care at the End-of-Life: One of the most troubling aspects of
health care reform legislation concerns end-of-life issues. In the
House bill (H.R. 3200, section 1233) it is unclear whether patients
could choose physician-assisted suicide in cases of terminal illness.
Amendments prevent ``promotion'' of assisted suicide, but not the
practice of it. And, there are potential conflicts in various sections
of the bill which preclude advance directives with a suicide or
assisted suicide option and those that have State exceptions (see
section 1233 and section 138).The Senate Finance Committee added a
modification prohibiting Federal funding for assisted suicide and a
conscience protection clause for those refusing to participate in
assisted suicide. (#C12, Page 17).
It is no secret that senior citizens require far more health care
than younger people. Any health care reform must provide effective
treatment for the Nation's older people--without curtailment,
withdrawal or denial of life-sustaining care for the terminally ill,
the chronically ill, or the permanently disabled. Further, those
provisions that address end-of-life issues must clearly leave no room
for an interpretation that would pressure healthcare providers to make
decisions based on cost rather than the best medical care.
conclusion
In conclusion, Concerned Women for America is concerned about some
key issues regarding abortion in the health care reform provisions. The
current bill contains required benefits that the courts can interpret
as covering abortion. The current bill precludes the Hyde Amendment
from applying to new funds. Current language requires health plans to
contract with abortion providers, like Planned Parenthood, and allows
abortion providers to receive identical non-discrimination protections.
Further, the bill could pre-empt some State anti-abortion laws.
CWA believes that for any health care legislation to pass Congress
it must protect life from conception to death. Therefore, we recommend:
1. First and foremost, abortion must be explicitly prohibited both
in funding and coverage, with the Hyde Amendment permanently codified
in law. The Enzi Amendment #276 ensures that taxpayer's dollars will
not be used to fund procedures that are ethically and morally
objectionable to a vast majority of Americans.
2. Second, the right to free exercise of their conscience must be
granted to all health care workers without penalty or intimidation. We
recommend the language of the Pitts/Stupak amendment to H.R. 3200
rather than the Kennedy Amendment to the Senate HELP bill.
3. Third, life-sustaining treatment must be available to all
citizens, including the elderly, terminally or chronically ill or those
who are permanently disabled.
4. Fourth, we categorically reject end-of-life counseling based on
cost considerations and government formulas generated by Comparative
Effectiveness Research. And, we reject all assisted suicide measures.
In the Old Testament, the very first commandment [the 5th
commandment--Exodus 20:12] given with a promise [that those who follow
the commandment will live long lives] is to honor your father and
mother. No nation can hope to prosper if it does not act in accordance
with this mandate. To claim that cutting Medicare by half a trillion
dollars will have no impact on senior citizen's benefits, mocks voters
and insults our intelligence. No amount of smoke and mirrors will
conceal the facts from the Nation's senior citizens.
Most of our senior citizens are women--most of whom have been
mothers. Those mothers are the backbone of the Nation; there is in the
very DNA of a mother the mandate to answer the call to sit in vigil
when a child or loved one is sick. Mothers generally do not begrudge
that labor in service to those that they love. It is an outrage to hear
politicians say to those mothers, in effect, that as old women whose
years of service are ended, it is time for you to quit consuming
resources . . . now roll over and die.
In a representative democracy, elected officials are honor bound to
represent those whom they serve. A November 2008 Zogby poll revealed 71
percent of Americans oppose government-funded abortion. Those of us who
come to give testimony and represent the public are free citizens,
grateful for the opportunity to give feedback and opinion on the issues
before this great body of legislators. We are not here summoned by
masters. We are not here intimidated by power. Instead, we are here
representing the views of thousands just like us who do not intend for
our choices to be limited or for our hard-fought liberties to be taken
away by those who would obfuscate, distort and hide the truth. No one
here today should forget that the citizenry of this great Nation has a
history of overthrowing tyranny. And nothing is a clearer act of
tyranny than for Congress to legislate change that abrogates our God-
given right to choose life.
It is clear that the current health care reform legislation would
classify abortion as an ``essential benefit'' and make it illegal for
health care workers to deny abortion to anyone who seeks it (regardless
of their personal convictions or beliefs). Further, it is clear that
the legislation will overrule State laws that require limitations such
as mandatory parental notification or waiting periods. It is also clear
that the current bills would force American citizens, whether they want
to or not, to subsidize abortion-on-demand with their tax dollars. Even
those with incomes up to 400 percent of poverty would receive subsidies
to pay for abortion.
Many things are negotiable and amenable to finding some middle
ground. But human life is sacred; thus, its defense is not open to
negotiation or compromise. Defending life is our sacred duty. It is
also a privilege to stand for those who are too vulnerable to stand for
themselves.
Senator Mikulski. Ms. Greenberger.
STATEMENT OF MARCIA D. GREENBERGER, FOUNDER AND CO-PRESIDENT,
NATIONAL WOMEN'S LAW CENTER, WASHINGTON, DC
Ms. Greenberger. Madam Chairwoman and members of the HELP
Committee, thank you very much for this opportunity to testify
on behalf of the National Women's Law Center. The center has
long advocated for national health care reform that meets
women's needs and we are, unfortunately, all too familiar with
the challenges that characterize women's everyday experiences
in the current health care system and, as has been described in
very graphic and moving terms by a number of the Senators on
this committee, subcommittee, among the most damaging are the
unfair and discriminatory practices of the health insurance
industry, including gender rating, the exclusion of health care
services that only women need, and preexisting condition
denials.
I would appreciate my full statement being made a part of
the record, and appended to it is a report that the National
Women's Law Center issued, ``Nowhere To Turn: How the
Individual Health Insurance''----
Senator Mikulski. I'm going to ask unanimous consent your
full statement be in the record, that Ms. Crouse's full
statement be in the record. All of you I know have a more
amplified one, and so let's just ask one unanimous consent. And
I appreciate everybody staying in the time line. Yours will be,
Ms. Crouse, and all others, who have a rather extensive one.
Ms. Greenberger. The report that the National Women's Law
Center prepared, which focused on the individual market in
particular, would be the subject of my brief remarks just now.
But I would hope in the questions to be able to address some of
the other issues that have been brought up with the members of
the panel this morning.
In 2008 the center study documented women's experiences
that have been described and showed what a difficult and unfair
place the individual market can be for women in particular.
Since then, we've also begun to speak out about the problems of
gender rating in insurance that affect the group market. The
very fact that employers also have to pay different rates for
their women employees versus their male employees serves as a
major disincentive for those employers who have a large number
of women employees in their workforce to be able to provide
adequate health care. Gender rating is not only a problem in
the individual market; it affects the entire health care
system, and we have found it in group association plans as
well.
With respect to gender rating, just a few additional
statistics to elucidate the unfairness. As much as 45 percent
more is what is charged for women at age 25 than men at age 25;
at age 40, as much as 48 percent more; and, as has been
described, those are figures excluding maternity care coverage.
Sixty-percent of plans that we surveyed did not offer even
a rider to cover maternity coverage. As has been described, if
you are reduced to having to buy that rider, it is
extraordinarily expensive and there are many limitations that
make the coverage inadequate.
A second issue. Some have said that, well, women just cost
more than men to insure. Well, that is not an answer that's
acceptable as a matter of common fairness and justice. But
let's look at some of the numbers as well. In looking at some
of the best-selling plans, we saw ranges where, for example, in
Arizona a 40-year-old woman was charged anywhere from 2 percent
to 51 percent more than a man; in Lincoln, NE, between 11
percent and 60 percent more than a man. Well, the idea that 11
percent is actuarially based and yet 60 percent could be
actuarially based strains credulity, to say the least, and we
have many other wild variations in the charges that are
imposed, because there isn't the protection in the law that
health care reform would provide to eliminate gender rating.
With respect to the group market, what we have been told
repeatedly is of employers with large percentages of women in
their workplace who have been told by their insurance companies
that what we see in rates can also reflect the gender
composition of that workplace. We have heard the statistics of
the difficulty women have in getting insurance, including that
they are often working for employers that don't provide health
care at all. Well, when those employers are charged more it's
hardly any wonder why that would be the case.
I want to skip now, with just a few seconds actually that I
have remaining, to make some specific recommendations with
respect to the differences in the plans. The HELP Committee
eliminates gender rating in all plans, in groups of all sizes.
That's a very important protection to be sure exists when these
bills are merged. That across the board protection is not in
the Finance Committee version right now.
Also, it's very important to be sure that the cost and the
affordability considerations are closer to the HELP plan for
all the reasons that have been described, of the difficulties
of women, who earn less than men, who have these greater out-
of-pocket costs, and who also end up often right now not only
going into bankruptcy, which we know is a major cause--caused
by health care costs, unfortunately, with loss of homes and
foreclosures and all of those things this country does not
need, but women in particular are vulnerable for that.
Also with respect to coverage, it's very important that
that coverage be comprehensive in nature. I want to say just a
few quick words about the idea that older women would end up
losing coverage.
Senator Mikulski. We don't want to muzzle or gag rule
anybody, but you've gone 2 minutes over.
Ms. Greenberger. Oh, OK. Well then, I'll wait for questions
and answers. But we don't agree with that.
Senator Mikulski. We certainly want to hear about those
older women.
Ms. Greenberger. And I could describe why we----
Senator Mikulski. Perhaps you could elaborate on that in
the Q and A's.
Ms. Greenberger. OK, yes, and with respect to reproductive
health care coverage I also disagree with some of those
comments that were made as well.
[The prepared statement of Ms. Greenberger follows:]
Prepared Statement of Marcia D. Greenberger
Madame Chairwoman and members of the committee on Health,
Education, Labor and Pensions, thank you for this opportunity to
testify on behalf of the National Women's Law Center. The Center is a
non-profit organization that has worked to expand the possibilities for
women and girls in this country since 1972. Since its founding, the
Center has confronted the health care coverage problems that women
face, which have extracted a high toll on women and their families. The
health care reform legislation now under debate can provide the major
improvements in health care quality and affordability that women and
their families so desperately need.
introduction
In particular, I want to focus on the results of the Center's
research for a report we published in 2008 called Nowhere to Turn: How
the Individual Health Insurance Market Fails Women, supplemented by the
stories of many individual women who have told us about the challenges
they encounter in the health system every day. A copy of the report* is
attached as an appendix to my testimony. Among the most deplorable of
these obstacles are the harmful and discriminatory practices of
insurance companies, including gender rating and coverage exclusions of
health care services that only women need. Regardless of whether they
receive their coverage from an employer via the group health insurance
market or are left to purchase health insurance directly from insurers
through the individual market, health insurance practices can hinder a
woman's ability to obtain affordable and comprehensive health care
coverage.
---------------------------------------------------------------------------
* The Report referred to may be found at: http://action.nwlc.org/
site/DocServer/Nowhere
toTurn.pdf.
---------------------------------------------------------------------------
The majority of American women have health insurance either through
an employer or through a public program such as Medicaid. In 2008,
nearly two-thirds of all women aged 18 to 64 had insurance through an
employer, and another 16 percent had insurance through a public
program.\1\ In addition, about 7 percent of nonelderly women purchase
health coverage directly from insurance companies in what is known as
the ``individual market.'' \2\ For the 18 percent of women who are
currently uninsured \3\--largely those who lack access to employer
coverage and who do not qualify for public programs--the individual
insurance market is often the last resort for coverage.
While women who get health insurance from their employer are
partially protected by both Federal and State employment discrimination
laws, States are left to regulate the sale of health insurance in the
individual market with no minimum Federal standards. In the vast
majority of States, few if any such protections exist for women who
purchase individual health coverage. Furthermore, those seeking health
coverage in the individual market are often less able to afford
insurance without the benefit of an employer to share the cost of the
premium.
The individual health insurance market presents numerous problems
for women, but even those who obtain group health insurance from their
employer are adversely affected by some of the same harmful practices
that impede access to affordable coverage in the individual market.
women face many challenges in the individual insurance market
To learn more about the experiences of women seeking coverage in
the individual insurance market, between July and September 2008, the
National Women's Law Center (``NWLC'' or ``the Center'') gathered and
analyzed information on over 3,500 individual health insurance plans
available through the leading online source of health insurance for
individuals, families and small businesses.\4\ The Center investigated
two phenomena: the ``gender gap''--the difference in premiums charged
to female and male applicants of the same age and health status--in
plans sampled from each State and the District of Columbia (DC), and
the availability and affordability of coverage for maternity care
across the country.\5\ NWLC examined State statutes and regulations
relating to the individual insurance market to determine whether the
States and Washington, DC have protections against premium rating based
on gender, age, or health status in the individual market, and to
determine whether States have any maternity coverage mandates requiring
insurers in the individual market to cover comprehensive maternity care
(defined as coverage for prenatal and postnatal care as well as labor
and delivery for both routine and complicated pregnancies).
Based on this research, NWLC found that the individual insurance
market is a very difficult place for women to buy health coverage.
Insurance companies can refuse to sell women coverage altogether due to
a history of any health problems whatsoever, or charge women higher
premiums based on factors that include gender, age and health status.
This coverage is often very costly and limited in scope, and it fails
to meet women's needs. In short, women face too many obstacles
obtaining comprehensive, affordable health coverage in the individual
market--simply because they are women.
Women often face higher premiums than men. Under a
practice known as gender rating, insurance companies are permitted in
most States to charge men and women different premiums. This costly
practice often results in wide variations in rates charged to women and
men for the same coverage. The Center's 2008 research on gender rating
in the individual market found that among insurers who gender rate, the
majority charge women significantly more than men until they reach
around age 55, and then some (though not all) charge men only somewhat
more.\6\ The Center also found huge and arbitrary variations in each
State and across the country in the difference in premiums charged to
women and men. For example, insurers who practice gender rating charged
40-year-old women from 4 percent to 48 percent more than 40-year-old
men.\7\ The huge variations in premiums charged to women and men for
identical health plans highlight the arbitrariness of gender rating,
and the financial impact of gender rating is compounded when insurers
also omit coverage for services that women need (like maternity care)
or charge a higher premium because a woman has a preexisting condition.
Insurance companies can deny applicants health coverage
for a variety of reasons that are particularly harmful to women. In the
vast majority of States, individual market insurers can use evidence of
a ``preexisting'' condition to deny coverage or exclude important
health benefits. Simply being pregnant or having had a Cesarean section
is grounds enough for insurance companies to reject a woman's
application.\8\ And in eight States and the District of Columbia,
insurers are allowed to use a woman's status as a survivor of domestic
violence to deny her health insurance coverage.\9\
It is difficult and costly for women to find health
insurance that covers maternity care. After reviewing over 3,500
policies available to women across the Nation in 2008, NWLC found that
the vast majority of individual market health insurance policies do not
cover maternity care at all. Just 12 percent included comprehensive
maternity coverage (i.e. coverage for pre- and post-natal visits as
well as labor and delivery, for both routine pregnancies and in case of
complications) within the insurance policy.
While women in some States may be able to purchase optional
maternity coverage (called a ``rider'') for an additional premium, the
extra cost can be prohibitively expensive; NWLC identified maternity
riders that cost over $1,000 per month, in addition to a woman's
regular insurance premium. Riders may also involve a waiting period (1
or 2 years, for example) and benefits are often limited in scope.\10\
Moreover, insurers that sell maternity riders typically offer just a
single rider option. Typically, a woman cannot select a more or less
comprehensive rider policy--her only option is to purchase the limited
rider or go without maternity coverage altogether.\11\
Other research confirms the dearth of maternity coverage in the
individual health insurance market. In California, for example, the
California Health Benefits Review Program found that only 22 percent of
the estimated 1,038,000 people in the individual market in California
in 2009 had maternity benefits--a dramatic decrease from the 82 percent
of people with individual policies that covered maternity in 2004.\12\
Both women and men face problems in the individual
insurance market that gender rating compounds. Insurance companies also
engage in premium rating practices that, while not unique to women,
compound the affordability issues caused by gender rating. These
include setting premiums based on age and health status.\13\
women face similar challenges in the group insurance market
The practice of gender rating also occurs in the group health
insurance market, most notably when employers obtain coverage for their
employees.\14\ Insurance companies in most States are allowed to use
the gender make-up of an insured group as a rating factor when
determining how much to charge the group for health coverage. From the
employee's perspective, this disparity may not be apparent, since
employment discrimination laws prohibit an employer from charging male
and female employees different rates for coverage, and employers
themselves often do not know the factors that determine the rates they
are charged. Yet gender rating in the group insurance market can
present a serious obstacle to affordable health coverage for an
employer and all of its employees. If the overall premium is not
affordable, a business may forgo offering coverage to workers
altogether, or shift a greater share of health insurance costs to
employees.
Gender rating may affect health premium costs for
employers of varying sizes. As a result of State and Federal employment
discrimination protections that apply to employer-provided fringe
benefit plans including health insurance, gender rating--while still
present in the group market--manifests itself differently than in the
individual market. Under Federal and most State laws, employers
unlawfully discriminate if they charge female employees more than male
employees for the same health coverage.
Nonetheless, when a business applies for health insurance, the
majority of States allow insurance companies to determine the premium
that will be charged using a process known as ``medical underwriting.''
As part of this process, an insurer considers various criteria--such as
gender, age, health status, claims experience, or occupation--and
decides how much to charge an applicant for health coverage. In the
large group market, insurers underwrite the group as a whole rather
than considering the health-related factors of each employee--but this
limitation provides little relief for employers with a high proportion
of female workers.\15\ Under the premise that women have, on average,
higher hospital and physicians' costs than men, insurance companies
that gender rate may charge employers more for health insurance if they
have a predominantly female workforce. This can raise premiums for all
employees and potentially move the employer to forgo providing health
coverage all together.
In the wide range of industries in which women dominate the
workforce, gender rating makes group health plan premiums harder to
afford. The fields of home health care and child care, for instance,
are majority-female (90 percent and 95 percent, respectively).\16\ More
than three-quarters of people employed by hospitals and physician's
offices are women, as are an estimated 82 percent of the employees in
dentists' offices.\17\ Women dominate the workforces of pharmacies and
drug stores (63 percent), retail florists (70 percent), and community
service organizations (69 percent).\18\ Over two-thirds of employees in
the nonprofit industry are women.\19\
discriminatory insurance industry practices contribute significantly
to women's affordability challenges
Unfair insurance industry practices--including gender rating,
denials based on preexisting conditions and exclusion of coverage for
essential needs like maternity care--exacerbate the affordability
problems that women are especially likely to face. Greater health care
needs,\20\ combined with a disadvantaged economic status and
discriminatory industry practices, make it difficult for many women to
afford necessary care.
Regardless of whether they have health insurance, women face more
cost-related challenges to securing access to health care than men.\21\
They generally have less income, earning only 77 cents, on average, for
every dollar that men earn.\22\ Roughly 57 percent of the adults living
in poverty (i.e. with incomes below 100 percent of the Federal poverty
level) are women.\23\ In 2008, the median earnings of female workers
working full time, year round, were $35,745, compared to $46,367 for
men.\24\
Women spend a greater share of their income on out-of-pocket
medical costs than men, and are more likely to avoid needed health care
because of cost. In 2007, for example, 52 percent of all nonelderly
women reported a cost-related access barrier--including not filling a
prescription, skipping a recommended test or treatment, or not getting
needed basic or specialist care because of cost--compared to 39 percent
of all nonelderly men.\25\
Women are also more likely than men to experience significant
financial hardship as a result of medical bills. In 2007, one-third of
women, compared to one-quarter of men, were either unable to pay for
food, heat or rent; had used up all of their savings; had taken out a
mortgage or loan against their home; or had taken on credit card debt
because of medical bills.\26\ Overall, 7 in 10 women are either
uninsured or underinsured, struggling to pay a medical bill, or
experiencing another cost-related problem in accessing needed care.\27\
some states have taken action to protect consumers in the individual
and small group markets
Some States have taken action to address the challenges that women,
and employers with female employees, face in the individual and group
markets.
Protections against gender rating: Because the regulation
of insurance has been largely left to the States,\28\ no Federal law
provides protections against gender rating in the individual and group
markets. Overall, 39 States and Washington, DC allow gender rating in
the individual market, with two of these States limiting the amount
premiums can vary based on gender through ``rate bands.'' \29\ However,
even States that ban gender rating allow some plans to use this
practice, such as the bare-bones basic and essential plans offered in
New Jersey.\30\ There are three basic approaches to prohibit or limit
gender rating in the individual market:
Explicit Protections against Gender Rating: Five
States in the individual market have passed laws prohibiting
insurers from considering gender when setting health insurance
rates: California,\31\ Minnesota,\32\ Montana,\33\ New
Hampshire,\34\ and North Dakota.\35\ California became the most
recent State to ban gender rating, through a bill that Governor
Schwarzenegger signed into law on October 11, 2009.
Community Rating: Currently, six States prohibit the
use of gender as a rating factor under community rating
statutes: New York imposes pure community rating \36\; while
Maine,\37\ Massachusetts,\38\ New Jersey,\39\ Oregon,\40\ and
Washington \41\ impose modified community rating that, in
addition to prohibiting rating based on health status, also
bans rating based on gender.
Gender Rate Bands: Some States have passed laws
limiting insurers' ability to base premiums on gender by
establishing a ``rate band,'' which sets limits between the
lowest and highest premium that a health insurer may charge for
the same coverage based on gender. In the individual market,
two States--New Mexico \42\ and Vermont \43\--use rate bands to
limit insurers' ability to vary rates based on gender.
In the group market, 12 States have banned gender rating
altogether. Three States have applied gender ``rate bands,'' and one
State prohibits gender rating unless the carrier receives prior
approval from the State insurance commissioner.
Explicit Protections against Gender Rating: Only one
State--Montana--prohibits insurers from using gender as a
rating factor in any type of insurance policy issued within the
State. Montana's distinctive ``unisex insurance law'' considers
gender rating to be discrimination against women, and bans the
practice among insurers issuing all types of insurance,
including health coverage, to individuals and groups of all
sizes.\44\
In addition, California,\45\ Colorado,\46\ Michigan,\47\ and
Minnesota,\48\ specifically prohibit insurers from considering
gender when setting health insurance rates in the small group
market.
Community Rating: New York \49\ imposes pure
community rating in its small group market, while Maine,\50\
Maryland,\51\ Massachusetts,\52\ New Hampshire,\53\ Oregon,\54\
and Washington,\55\ ban gender-based rating under modified
community rating.
Gender Rate Bands: Three States--Delaware,\56\ New
Jersey,\57\ and Vermont,\58\ limit the extent to which insurers
may vary premium rates based on gender through a rate band.
Other: One State, Iowa,\59\ prohibits gender rating
unless a small group insurance carrier secures prior approval
from the State insurance commissioner.
It is important to note that with the exception of Montana, the
States' group market gender rating regulations apply only to health
insurance sold to small groups. Most States use an upper size limit of
50 members/employees to define a small group, though a few have
established limits as low as 25 members.\60\ In nearly all of the
States with group market protections against gender rating, therefore,
employers that exceed the State-defined size limit--including those
with as few as 51 employees--are still subject to this discriminatory
practice.
Maternity mandates: The Federal Pregnancy Discrimination
Act protects women in covered employer-provided health plans against
the exclusion of maternity benefits,\61\ but no similar Federal
protection exists for women in the individual market. A handful of
States have recognized the importance of ensuring that maternity
coverage--including prenatal, birth, and postpartum care--is a part of
basic health care by establishing a ``benefit mandate'' law that
requires insurers to include coverage for maternity services in all
individual health insurance policies sold in their State. Currently,
just five States have enacted mandate laws that require all insurers in
the individual market to cover the cost of maternity care. These States
are: Massachusetts,\62\ Montana,\63\ New Jersey,\64\ Oregon,\65\ and
Washington.\66\ In New Jersey and Washington, individual insurance
providers are allowed to offer bare-bones plans that are exempt from
the mandate and exclude maternity coverage.\67\
Beyond this short list of five, other States have adopted limited-
scope mandate laws for the individual market that require maternity
coverage only for certain types of health plan carriers, certain types
of maternity care, or for specific categories of individuals. Limited-
scope mandate laws address the provision of maternity care but may fall
short of providing women with full coverage for the care they need. In
California,\68\ Illinois,\69\ and Georgia,\70\ for example, only Health
Maintenance Organizations (HMOs) are subject to State laws that mandate
maternity benefits in the individual insurance market.
With regard to the group market, some States have taken an
additional step to guarantee that women who work for small businesses
have access to employer-
sponsored insurance that includes maternity benefits, since employers
with fewer than 15 workers are not subject to the Federal Pregnancy
Discrimination Act law requiring businesses to provide the same level
of coverage for pregnancy as is provided for other medical conditions.
By adopting laws that mandate the inclusion of maternity benefits in
policies sold through the State's group health insurance market, States
ensure that all women with group health plans have access to these
important benefits, no matter how small the employer. Fifteen States
have enacted such laws, though they may apply only to certain types of
health plans such as managed care plans.\71\ Therefore, it is possible
that in some States women who obtain ESI through a small business do
not receive maternity benefits as part of that coverage.
State maternity coverage programs: In a few instances,
State governments have stepped in (at taxpayer expense) to fill gaps in
private health insurance by establishing programs to assist pregnant
women who have private coverage that does not meet their maternity care
needs. At least two States have such programs: California's Access for
Infants and Mothers (AIM) program is a low-cost coverage program for
pregnant women who are uninsured and ineligible for Medi-Cal (the
State's Medicaid program).\72\ New Mexico's Premium Assistance for
Maternity (PAM) program is a State-sponsored initiative that provides
maternity coverage for pregnant citizens who are ineligible for
Medicaid.\73\ According to program officials in New Mexico, PAM was
established expressly because of the gaps that existed in private
market maternity coverage. If maternity care was included as a basic
benefit in comprehensive and affordable health insurance policies, such
programs would be unnecessary.
recommendations for health care reform
Health reform holds the promise of making affordable care available
to millions of women who need it. As the legislation progresses in the
coming weeks, however, it is essential that robust insurance market
reforms are included, as well as other provisions to ensure that health
care is truly affordable. If these key pieces are absent from the final
legislation, health reform will provide inferior coverage and
protection to the millions of women who are currently struggling to get
the care they need. Specifically, to protect women and their families
health care reform must:
Include insurance market reforms that protect ALL women,
whether they obtain coverage on their own, get health benefits from an
employer, or secure coverage from other types of plans. Health reform
must eliminate unfair and discriminatory practices, such as gender
rating and preexisting condition exclusions, by applying reforms
broadly across the individual market and for all groups of all sizes.
It must ensure that reforms protect women from unfair practices
regardless of whether they obtain coverage through the new Health
Insurance Exchanges, from an employer of any size (not just a small
business), or an association health plan. Limiting reforms to a subset
of the health insurance market--such as for individuals and small
groups only--creates a loophole for insurance companies and squanders
an opportunity to ensure uniform and fair rules for all women with
health insurance. It allows moderate-sized and large groups to continue
facing unfair and costly insurance practices related to the sex, age,
or health claims history of their employees.
Eliminating gender rating and other discriminatory practices for
individuals and groups of all sizes is especially important given other
potential health reform provisions, such as the proposed excise tax on
so-called ``high-cost'' health plans. Plans--and ultimately
individuals--may be subject to the tax due to the gender, age, or
health status of the enrolled individual or group if unfair premium
rating practices are allowed to continue.
Ensure affordable coverage. Affordability in health reform
is especially important for women. There are more than 14 million
uninsured women (ages 18-64) with incomes below 400 percent of the
Federal poverty level.\74\ Without sufficient subsidies to help with
the cost of health insurance, women in this income range would struggle
to afford newly-available coverage and could even join the ranks of the
underinsured. For a single mom with two children at 400 percent of
poverty, the average premium cost for a Blue Cross standard policy
alone would be almost 18 percent of her income.
Accordingly, there must be adequate sliding scale subsidies for
premiums and out-of-pocket costs--as well as reasonable limits on total
out-of-pocket costs--so that women can obtain health coverage that they
can realistically afford. The legislation reported by the Health,
Education, Labor, and Pensions Committee (S. 1679) provides stronger
affordability protections than the legislation reported by the Finance
Committee.
Prohibit any annual or lifetime benefit caps for all
individual and group health insurance plans. Even benefit limits that
appear to be high can be used up quickly if a woman faces a serious
condition, leaving little or no coverage for a woman's other basic
health care needs. For example, a woman suffering from coronary artery
disease, the leading killer of women in the United States, could spend
over $1 million over the course of her lifetime on related treatment
alone,\75\ and a condition such as multiple sclerosis--which affects
twice as many women as men \76\--costs an estimated $2.2 million over
the course of an individual's lifetime.\77\ This critically important
protection will help women afford health care when they need it most,
as well as avoid medical debt and bankruptcy.
conclusion
Women's relationship with the health system is characterized by
many disadvantages, including continued discrimination by health
insurance companies and increasing proportions who report cost-related
problems with access to care. Quite simply, there is an urgent need for
health reform now, to make affordable, high-quality health care a
reality for women across the country.
The country is closer than ever been before to realizing this goal,
but the debate over the scope of insurance market reforms and various
other provisions to ensure affordable coverage is far from over. The
protections that are of fundamental importance for women are essential
components of health reform. For women and their families, health
reform that assures affordability and fairness will mean the difference
between securing access to quality health care, and going without.
References
1. National Women's Law Center analysis of 2008 data on health
coverage from the Current Population Survey's Annual Social and
Economic Supplement (U.S. Census Bureau, 2009) using CPS Table Creator,
http://www.census.gov/hhes/www/cpstc/cps_table_creator.html.
2. Id.
3. Id.
4. This source is eHealthInsurance, available at http://
www.ehealthinsurance
.com/. Notably, eHealthInsurance may not represent all insurance
companies
licensed to sell individual health insurance policies in every State.
However, the company bills itself as the leading online source of
health insurance for individuals, families, and small businesses,
partnering with over 160 health insurance companies in 50 States and
Washington, DC and offering more than 7,000 health insurance products
online. NWLC chose to use eHealthInsurance for this study because it
presents the clearest available picture of the individual market across
the country, and because it is the most readily available tool for
individuals seeking private insurance who do not wish, or cannot
afford, to employ the services of an insurance agent. Any limitations
in eHealthInsurance's scope--in tandem with the basic fact that its
services are only available online and therefore may not be accessible
to individuals without a computer or Internet access or who are not web
savvy--simply underscores the challenges women (and men) face seeking
coverage in the individual market without a government-sponsored system
to help facilitate their search.
5. While NWLC's review of health insurance plans examined coverage
for maternity-related care, it was much more difficult to determine
whether other pregnancy-related benefits, such as contraception or
pregnancy termination, are covered under a plan; accordingly, our
review did not include these important reproductive health benefits.
For example, in many plan brochures, if information about either of the
above benefits is available at all, it is visible only as part of a
long list of exclusions. This obfuscation reflects another challenge
women face in assessing the adequacy of a plan's coverage.
6. Lisa Codispoti, Brigette Courtot and Jen Swedish, Nat'l Women's
Law Ctr, Nowhere to Turn: How the Individual Market Fails Women (Sept.
2008), http://action.nwlc.org/site/PageServer?pagename=nowheretoturn.
7. Id.
8. Denise Grady, After Caesareans, Some See Higher Insurance Cost,
N.Y. Times, June 1, 2008, at A26, available at http://www.nytimes.com/
2008/06/01/health/01insure.html.
9. Women's Law Project & Pennsylvania Coalition Against Domestic
Violence, FYI: Insurance Discrimination Against Victims of Domestic
Violence, 2002 Supplement 2 (2002), http://www.womenslawproject.org/
brochures/InsuranceSup_DV
2002.pdf. In the early 1990s, advocates discovered that insurers had
denied applications for coverage submitted by women who had experienced
domestic violence. See, e.g., 142 Cong. Rec. E1013-03, at E1013-14
(June 5, 1996) (statement of Rep. Pomeroy) (``the Pennsylvania State
Insurance Commissioner surveyed company practices in Pennsylvania and
found that 26 percent of the respondents acknowledged that they
considered domestic violence a factor in issuing health, life and
accident insurance''). Since 1994, the majority of States have adopted
legislation prohibiting health insurers from denying coverage based on
domestic violence, but nine States and Washington, DC offer no such
protection to survivors of domestic violence. Even though Vermont lacks
legislation specifically prohibiting discrimination against domestic
violence survivors, the State requires guaranteed issue of all
individual insurance plans. See infra note 94 and accompanying text.
Though the report identifies nine States, as well as the District of
Columbia, which do not prohibit this practice, Arkansas Gov. Beebe
recently signed into law ACT 619, which amends Arkansas Code 23-66-
206(14)(G), to add ``status as a victim of domestic abuse'' to the list
of attributes that insurers may not use as the sole justification for
denying an individual health insurance coverage.
10. It is quite common for a rider to limit the total maximum
benefit to amounts such as $3,000 (available only after a 10-month
waiting period for a rider option identified in the District of
Columbia) or $5,000 (available only after a 12-month waiting period for
an Arkansas rider option).
11. Id.
12. California Health Benefits Review Program, Executive Summary:
Analysis of Assembly Bill 98: Maternity Services, A Report to the 2009-
2010 California Legislature (Mar. 16, 2009), http://www.chbrp.org/
documents/ab_98_fnlsumm.pdf.
13. Nowhere to Turn, supra note 6.
14. There are also non-employer based group plans that provide
insurance, commonly referred to as association health plans.
15. Id.; Henry J. Kaiser Family Foundation, How Private Health
Coverage Works: A Primer, 2008 Update (Apr. 2008), http://www.kff.org/
insurance/upload/7766.pdf.
16. U.S. Bureau of Labor Statistics, Women in the Labor Force: A
Data Book, 2008 Edition (2008), ``Table 14: Employed Persons by
Detailed Industry and Sex, 2007 Annual Averages,'' http://www.bls.gov/
cps/wlf-databook-2008.pdf.
17. Id.
18. Id.
19. Jasmine McGinnis, Georgia State University and Georgia
Institute of Technology, The Young and Restless: Generation Y in the
Nonprofit Workforce (Working Paper, 2009), http://www.utexas.edu/lbj/
rgk/fellowship/2009papers/McGinnis.pdf.
20. Women are more likely than men to require health care
throughout their lives, including regular visits to reproductive health
care providers. They are more likely to have chronic conditions that
necessitate continuous health care treatment. They also use more
prescription drugs on average, and certain mental health problems
affect twice as many women as men. See: Elizabeth Patchias and Judy
Waxman, Women and Health Coverage: The Affordability Gap (2007),
National Women's Law Center. An issue brief prepared for the
Commonwealth Fund, available at http://www.nwlc.org/pdf/
NWLCCommonwealthHealthInsuranceIssueBrief2007.pdf (last visited May, 12
2008).
21. Sheila D. Rustgi, Michelle M. Doty, and Sara R. Collins, Women
at Risk: Why Many Women are Forgoing Needed Health Care (New York: The
Commonwealth Fund, May 2009).
22. U.S. Census Bureau (Sept 2009), Men's and Women's Earnings by
State: 2008 American Community Survey, http://www.census.gov/prod/
2009pubs/acsbr08-3.pdf.
23. National Women's Law Center calculations based on U.S. Census
Bureau, ``Table POV01: Age and Sex of All People, Family Members and
Unrelated Individuals Iterated by Income-to-Poverty Ratio and Race:
2005, Below 100 percent of Poverty--All Races.'' Current Population
Survey Annual Demographic Survey March Supplement, (2006), available
at: http://pubdb3.census.gov/macro/032006/pov/new01_100_01.htm. (last
visited May 12, 2008).
24. National Women's Law Center, Women's Private Health Coverage,
Incomes Decline While Poverty Increases, Census Data Show (September
2009 Press Release), http://www.nwlc.org/
details.cfm?id=3711§ion=newsroom.
25. Women at Risk, supra note 21.
26. Id.
27. Id.
28. McCarran-Ferguson Act, 15 U.S.C. 1011-1015 (2008).
29. Nowhere to Turn, supra note 6.
30. N.J. Dept. of Banking & Ins., N.J. Individual Health Coverage
Program Buyer's Guide: How To Select a Health Plan--2006 Ed. (2006),
http://www.state.nj.us/dobi/division_insurance/ihcseh/ihcbuygd.html
(``carriers may vary the rates for the B&E plan based on age, gender
and geographic location'').
31. On October 11, 2009, California governor Arnold Schwarzenegger
signed Assembly Bill 119, which prohibits gender rating in the State's
insurance markets, into law. The law affects insurance policies issued
or renewed on or after January 1, 2011.
32. MN. Stat. 62A.65(4) (2008) (``No individual health plan
offered, sold, issued, or renewed to a Minnesota resident may determine
the premium rate or any other underwriting decision, including initial
issuance, through a method that is in any way based upon the gender of
any person covered or to be covered under the health plan.'').
33. MT. Code Ann. 49-2-309(1) (2008) (``It is an unlawful
discriminatory practice for a financial institution or person to
discriminate solely on the basis of sex or marital status in the
issuance or operation of any type of insurance policy, plan, or
coverage or in any pension or retirement plan, program, or coverage,
including discrimination in regard to rates or premiums and payments or
benefits.''). Montana's ``unisex insurance law'' is not limited to
health insurance; it prohibits insurers from using gender as a rating
factor in any type of insurance policy issued within the State. See
Mont. Code Ann. 49-2-309(1) (2008) (``It is an unlawful
discriminatory practice for a financial institution or person to
discriminate solely on the basis of sex or marital status in the
issuance or operation of any type of insurance policy, plan, or
coverage or in any pension or retirement plan, program, or coverage,
including discrimination in regard to rates or premiums and payments or
benefits'').
34. N.H. Rev. Stat. Ann. 420-G:4(I)(d) (2008) (allowing insurers
to base rates in the individual market solely on age, health status,
and tobacco use).
35. N.D. Cent. Code 26.1-36.4-06(1) (2008) (imposing a rate band
under which age, industry, gender, and duration of coverage may not
vary by a ratio of more than 5 to 1, but providing that ``[g]ender and
duration of coverage may not be used as a rating factor for policies
issued after January 1, 1997''). Despite the statutory prohibition on
gender rating in North Dakota, the only company offering individual
policies through www.eHealthInsurance.com does use gender as a rating
factor. In an attempt to understand this seeming inconsistency, NWLC
contacted the North Dakota Insurance Department, which indicated that
this company is a ``hybrid situation'' and thus permitted to rate its
individual policies as if they were sold on the group market; gender
rating is allowed within limit for groups in North Dakota. Telephone
Interview with North Dakota Insurance Department (Sept. 12, 2008).
36. N.Y. Ins. Law 3231(a) (McKinney 2008) (defining community
rating as ``a rating methodology in which the premium for all persons
covered by a policy or contract form is the same based on the
experience of the entire pool of risks covered by that policy or
contract form without regard to age, sex, health status or
occupation'').
37. ME. Rev. Stat. Ann. tit. 24-A, 2736-(2)(B) (2008)
(prohibiting insurance carriers from varying the community rate due to
gender or health status). ME. Rev. Stat. Ann. tit. 24-A, 2736-
C(2)(D)(3) (2008) (imposing a rate band under which insurance carriers
may only vary the community rate due to age by plus or minus 20 percent
for policies issued after July 1, 1995).
38. MA. Gen. Laws ch. 176M, 1 (2008) (defining ``modified
community rate'' as ``a rate resulting from a rating methodology in
which the premium for all persons within the same rate basis type who
are covered under a guaranteed issue health plan is the same without
regard to health status; provided, however, that premiums may vary due
to age, geographic area, or benefit level for each rate basis type as
permitted by this chapter''). Mass. Gen. Laws ch. 176M, 4(a)(2)
(2008) (imposing a rate band under which the ``premium rate adjustment
based upon the age of an insured individual'' may range from 0.67 to
1.33).
39. 2008 N.J. Sess. Law Serv. Ch. 38, page nos. 12, 15 (Senate
1557) (West) (amending N.J. Stat. Ann. 17B:27A-2 (West 2008) to
define ``modified community rating'' as ``a rating system in which the
premium for all persons under a policy or a contract for a specific
health benefits plan and a specific date of issue of that plan is the
same without regard to sex, health status, occupation, geographic
location or any other factor or characteristic of covered persons,
other than age,'' and amending N.J. Stat. Ann. 17B:27A-4 (West 2008)
to require individual health benefits plans to ``be offered on an open
enrollment, modified community-rated basis''). New Jersey law excludes
bare-bones basic and essential plans from the modified community-
rating requirement.
40. OR. Rev. Stat. 743.767(2) (2008) (``The premium rates charged
during a rating period for individual health benefit plans issued to
individuals shall not vary from the individual geographic average rate,
except that the premium rate may be adjusted to reflect differences in
benefit design, family composition and age.'').
41. WA. Rev. Code 48.43.005(1) (2008) (defining ``adjusted
community rate'' as ``the rating method used to establish the premium
for health plans adjusted to reflect actuarially demonstrated
differences in utilization or cost attributable to geographic region,
age, family size, and use of wellness activities''); Wash. Rev. Code
48.44.022(1)(a) (2008) (allowing insurers to only vary the adjusted
community rate based on geographic area, family size, age, tenure
discounts, and wellness activities).
42. N.M. Stat. 59A-18-13.1(A) (2008) (allowing gender rating);
N.M. Stat. 59A-18-13.1(B) (2008) (providing that ``the difference in
rates in any one age group that may be charged on the basis of a
person's gender shall not exceed another person's rates in the age
group by more than 20 percent of the lower rate'').
43. VT. Stat. Ann. tit. 8, 4080b(h)(1) (2008) (prohibiting the
use of the following rating factors when establishing the community
rate: demographics including age and gender, geographic area, industry,
medical underwriting and screening, experience, tier, or duration); VT.
Stat. Ann. tit. 8, 4080b(h)(1) (2008), 21-020-034 VT. Code R. 93-
5(11)(G), (13)(B)(6) (2008) (providing that upon approval by the
insurance commissioner, insurers may adjust the community rate by a
maximum of 20 percent for demographic rating including age and gender
rating, geographic area rating, industry rating, experience rating,
tier rating, and durational rating).
44. MT. Code Ann. 49-2-309(1) (2008).
45. CA. Ins. Code 10714(a)(2), 10700(t)--(v) (West 2008)
(prohibiting small employer insurance carriers from setting premium
rates based on characteristics other than age, geographic region, and
family size, in addition to the benefit plan selected by the employee).
46. CO. Rev. Stat. 10-16-105(8)(a), 10-16-102(10)(b) (2008)
(prohibiting small employer insurance carriers from setting premium
rates based on characteristics other than age, geographic region,
family size, smoking status, claims experience, and health status).
47. MI. Comp. Laws 500.3705(2)(a) (2008) (prohibiting commercial
small employer insurance carriers from setting premium rates based on
characteristics of the small employer other than industry, age, group
size, and health status).
48. MN. Stat. 62L.08(5) (2008) (prohibiting the use of gender as
a rating factor for small employer insurance carriers).
49. N.Y. Ins. Law 3231(a) (McKinney 2008) (requiring all small
employer insurance plans to be community rated and defining ``community
rating'' as ``a rating methodology in which the premium for all persons
covered by a policy or contract form is the same based on the
experience of the entire pool of risks covered by that policy or
contract form without regard to age, sex, health status or
occupation'').
50. ME. Rev. Stat. Ann. tit. 24-A, 2808-B(2)(B) (2008)
(prohibiting small employer insurance carriers from varying the
community rate based on gender, health status, claims experience or
policy duration of the group or group members).
51. MD. Code Ann., Ins. 15-1205(a)(1)-(3) (West 2008) (allowing
small employer insurance carriers to adjust the community rate only for
age and geography).
52. MA. Gen. Laws ch. 176J, 3(a)(1), (2) (2008) (allowing small
employer insurance carriers to adjust the community rate only for age,
industry, participation-rate, wellness program, and tobacco use).
53. N.H. Rev. Stat. Ann. 420-G:4(1)(e)(1) (2008) (prohibiting
small employer insurance carriers from setting premium rates based on
characteristics of the small employer other than age, group size, and
industry classification).
54. OR. Rev. Stat. 743.737(8)(b)(B) (2008) (providing that small
employer insurance carriers may only vary the community rate based on
age, employer contribution level, employee participation level, the
level of employee engagement in wellness programs, the length of time
during which the small employer retains uninterrupted coverage with the
same carrier, and adjustments based on level of benefits). Overall Rate
Band: 50 percent
55. WA. Rev. Code 48.21.045(3)(a) (2008) (providing that small
employer insurance carriers may only vary the community rate based on
geographic area, family size, age, and wellness activities).
56. DE. Code Ann. tit. 18, 7205(2)(a) (2008) (allowing small
employer insurance carriers to vary premium rates based on gender and
geography combined by up to 10 percent). Age: DE. Code Ann. tit. 18,
7202(9), 7205 (2008) (allowing the use of age as a rating factor if
actuarially justified).
57. N.J. Stat. Ann. 17B:27A-25(a)(3) (West 2008) (providing that
the premium rate charged by a small employer insurance carrier to the
highest rated small group shall not be greater than 200 percent of the
premium rate charged to the lowest rated small group purchasing the
same plan, ``provided, however, that the only factors upon which the
rate differential may be based are age, gender and geography''). Rate
Band for Age, Gender & Geography: 200 percent.
58. VT. Stat. Ann. tit. 8, 4080a(h)(1) (2008) (prohibiting the
use of the following rating factors when establishing the community
rate: demographics including age and gender, geographic area, industry,
medical underwriting and screening, experience, tier, or duration); VT.
Stat. Ann. tit. 8, 4080a(h)(2) (2008) (providing that upon approval
by the insurance commissioner, insurers may adjust the community rate
by a maximum of 20 percent for demographic rating including age and
gender rating, geographic area rating, industry rating, experience
rating, tier rating, and durational rating). Overall Rate Band: 20
percent.
59. IA Code 513B.4(2) (2008) (prohibiting the use of rating
factors other than age, geographic area, family composition, and group
size without prior approval of the insurance commissioner).
60. In Louisiana, for instance, a small group has 35 or fewer
members; Arkansas and Tennessee define a small group as one that has 25
or fewer members. (Unpublished research conducted by the National
Women's Law Center, 2009).
61. Pub. L. No. 95-555, 92 Stat. 2076 (1978).
62. MA. Gen. Laws ch. 176G, 4(c), 4I (2008) (requiring health
maintenance organizations to include maternity coverage); MA. Gen. Laws
ch. 176B, 4H (2008) (requiring medical service corporations to
include maternity coverage); MA. Gen. Laws ch. 176A, 8H (2008)
(requiring non-profit hospital service corporations to include
maternity coverage).
63. MT. Ins. Or. (Feb. 16, 1994); Bankers Life & Casualty Co. v.
Peterson, 866 P.2d 241 (Mont. 1993). Mandated maternity coverage is not
always imposed by State legislation or via administrative regulations.
Montana's mandate is the result of a 1993 State Supreme Court decision
which held that a health plan excluding maternity coverage
unconstitutionally discriminated based on gender.\74\ In response to
this court decision, the Montana Insurance Commissioner issued an order
that all insurers in the State must include maternity benefits.\75\
64. N.J. Stat. Ann. 17B:26-2.1b (West 2008) (requiring all
individual plans, except the bare-bones basic and essential plans, to
include maternity coverage). N.J. Dept. of Banking & Ins., N.J.
Individual Health Coverage Program Buyer's Guide: How To Select a
Health Plan--2006 Ed. (2006), http://www.state.nj.us/dobi/
division_insurance/ihcseh/ihcbuygd.html (``carriers may vary the rates
for the B&E plan based on age, gender and geographic location'').
65. OR. Rev. Stat. 743A.080 (2008).
66. WA. Rev. Code 48.43.041(1)(a) (2008) (requiring all
individual plans, except the bare-bones catastrophic plans, to include
maternity coverage).
67. Id.; N.J. Dept. of Banking & Ins., supra note 8 (``B&E Plans do
not provide comprehensive benefits like the standard plans described
above,'' which include prenatal and maternity care).
68. CA. Health & Safety Code 1367(i) (requiring health care
service plans to provide basic health care services); A.B. 1962, 2007-
2008 Sess. 1 (Cal. 2008) (recognizing that, in practice, health care
service plans are required to provide maternity services as a basic
health care benefit).
69. IL. Admin. Code tit. 50, 5421.130(e) (2008).
70. GA. Comp. R. & Regs. 290-5-37-.03(4) (2008).
71. HI, MD, MA, MI, MN, MT, NJ, NY, OR, VT, and WA have enacted
laws requiring maternity benefits in all policies for employers in the
small group market. ID requires that maternity benefits be covered for
employers with five or more employees, and CA, GA, and ME have laws
require that maternity be covered by managed care organizations in the
small group market. See: Ed Neuschler, Institute for Health Policy
Solutions, Policy Brief on Tax Credits for the Uninsured and Maternity
Care 3 (March of Dimes 2004), http://www.marchofdimes.com/Tax
CreditsJan2004.pdf.
72. Managed Risk Medical Insurance Board, Access for Infants and
Mothers, http://www.aim.ca.gov/english/AIMHome.asp (last visited Sept.
17, 2008).
73. Insure New Mexico, Premium Assistance for Maternity (PAM)
Frequently Asked Questions, http://www.insurenewmexico.state.nm.us/
PAMFaqs.htm (last visited Sept. 17, 2008).
74. National Women's Law Center calculations based on health
insurance data for women ages 18-64 from the Current Population
Survey's 2008 Annual Social and Economic Supplement, using CPS Table
Creator, http://www.census.gov/hhes/www/cpstc/cps_table_creator.html.
75. Leslee J. Shaw; C. Noel Bairey Merz; Carl J. Pepine, et al.,
The Economic
Burden of Angina in Women With Suspected Ischemic Heart Disease,
Circulation
114 (2006):894-904, http://circ.agajournals.org/cgi/content/abstract/
114/9/894?
maxtoshow =&HITS =10&hits=10&RESULTFORMAT=&fulltext=cardiovascular&
searchid=1&FIRSTINDEX=20&resourcetype=HWFIG.
76. Brigham and Women's Hospital, ``Focus on Multiple Sclerosis''
(April 2008), http://www.brighamandwomens.org/patient/healthmatters/
multiplesclerosis.aspx.
77. Kathryn Whetten-Goldstein, Frank A. Sloan, Larry B. Goldstein,
et al., A Comprehensive Assessment of the Cost of Multiple Sclerosis in
the United States, Multiple Sclerosis 4, no. 5 (1998):419-425, http://
msj.sagepub.com/cgi/content/abstract/4/5/419.
Senator Mikulski. Ms. Buchanan.
STATEMENT OF AMANDA BUCHANAN, PATIENT/HEALTH CARE CONSUMER,
WEISER, ID
Ms. Buchanan. Madam Chair, members of the committee, I
would like to thank you for giving me the opportunity to
testify before this committee today. My name is Amanda Buchanan
and I live in Weiser, ID. I am the wife of a public school
teacher and a mother to two young sons.
My husband transferred from a large school district to a
small rural one shortly after my first son was born. The
decrease in income this change created was a compromise for our
desire to raise a family in a small town. We have always been
great at living simply and frugally, which came in especially
handy as I had decided to become a stay-at-home mom.
However, what we weren't prepared for was the astronomical
cost of putting myself and my infant son on my husband's group
insurance policy--$760 a month on a $33,000 a year gross
income. For the first time I decided to get individual market
coverage for the baby and me. I quickly learned that in Idaho
as an individual searching for coverage I had two options,
Regents Blue Shield of Idaho and Blue Cross of Idaho, and the
limited options available between these two companies were
remarkably similar. In fact, every single policy available,
despite the premium and deductible level, came with an
additional maternity deductible of $5,000 plus 20 percent of
all remaining costs.
At the time, my focus was on being responsible, which to me
meant having insurance. I wasn't planning on getting pregnant
for some time and I really had no other choice. Several months
later, my husband and I found ourselves answering the
possibility of a second child. Instead of an intimate
conversation between the two of us about goals and family, I
felt like there were actually three of us at the table: myself,
my husband, and our insurance policy.
We had to decide if we could even afford to have a second
child, and not ``afford'' in the sense of clothing, food, et
cetera, but could we afford to pay a hospital bill. There I
was, paying a $280 premium every month for the best individual
market policy Regents offered, and I was having to debate if I
could afford the medical bills from a routine pregnancy and
delivery.
I was very angry that an insurance company could set up a
policy in a way that would either discourage women from getting
pregnant altogether or, if they did become pregnant, force them
to pay for basically the entire cost of a typical delivery.
My husband and I came up with a plan. I would have a baby,
then take myself off of insurance and use the money I'd save to
pay down our medical debt, and this is exactly what we did. In
the end, health care premiums, deductibles, and the medical
costs from the pregnancy and delivery ate up 28 percent of our
net income in 2008, and this is even after the hospital wrote
off our bill.
As it stands, our medical debts are paid. I remain
uninsured. You could argue that I'm being irresponsible and
creating a potentially disastrous situation for my family, and
I would agree with you. But it would be impossible for us to
come up with $300 a month to cover me. We would be sacrificing
any ability to save money for emergencies and would most
definitely be cutting into our grocery budget.
As a mother, my responsibility is to my children and
family. My sons remain well-fed and insured. I also have the
responsibility of taking care of myself. Fortunately, I am a
healthy woman. Even so, my lack of insurance is a constant
source of stress.
I am tired of the tactics insurance companies use to make
quality coverage unaffordable, tactics that include outrageous
separate deductibles for the common condition of pregnancy. I
do not trust these companies and certainly do not believe that
they will ever have the best interests of patients at heart. I
want an affordable public option that will provide quality
coverage and the assurance that out-of-pocket costs will be
reasonable and fair. Health insurance premiums should be a part
of every family's budget. However, they should not be a
crippling part.
My family could live comfortably on my husband's salary if
our insurance premiums were reasonably proportionate to our
income. We have made many minor sacrifices in order for me to
remain at home with our children. However, in this day and age
and in this great country I should not have to sacrifice basic
health care coverage as well.
Thank you for your time.
[The prepared statement of Ms. Buchanan follows:]
Prepared Statement of Amanda Buchanan
Mr. Chair, members of the committee, I would like to thank you for
giving me the opportunity to testify before this committee today. My
name is Amanda Buchanan, and I live in Weiser, ID. I am the wife of a
public school teacher and a mother to two young sons.
My husband transferred from a large school district to a small,
rural one shortly after my first son was born. The decrease in income
this change created was a compromise for our desire to raise a family
in a small town. We have always been great at living simply and
frugally--which came in especially handy as I had decided to become a
stay-at-home mom. However what we weren't prepared for was the
astronomical cost of putting myself and my infant son on my husband's
group insurance policy. ($760 a month on a $33,000 a year gross
income.) For the first time, I decided to get individual market
coverage for the baby and me.
I quickly learned that in Idaho, as an individual searching for
coverage, I had two options: Regence Blue Shield of Idaho and Blue
Cross of Idaho. And the limited options available between these two
companies were remarkably similar. In fact every single policy
available, despite the premium and deductible level, came with an
additional maternity deductible of $5,000 (plus 20 percent of all
remaining costs). At the time, my focus was on being responsible, which
to me meant having insurance. I wasn't planning on getting pregnant for
some time and I really had no other choice.
Several months later, my husband and I found ourselves discussing
the possibility of a second child. Instead of an intimate conversation
between the two of us about goals and family, I felt like there were
actually three of us at the table--myself, my husband and our insurance
policy. We had to decide if we could even afford to have a second
child. And not ``afford'' in the sense of clothing, food, et cetera;
but could we afford to pay a hospital bill? There I was paying a $280
premium every month for the best individual market policy Regence
offered, and I was having to debate if I could afford the medical bills
from a routine pregnancy and delivery. I was very angry that an
insurance company could set up a policy in a way that would either
discourage women from getting pregnant altogether, or if they did
become pregnant, force them to pay for basically the entire cost of a
typical delivery.
My husband and I came up with a plan: I would have a baby, then
take myself off of insurance and use the money I'd save to pay down our
medical debt. And this is exactly what we did. In the end, health care
premiums, deductibles and the medical costs from the pregnancy and
delivery ate up 28 percent of our net income in 2008. And this is even
after the hospital wrote off our bill.
As it stands, our medical debts are paid. I remain uninsured. You
could argue that I'm being irresponsible and creating a potentially
disastrous situation for my family, and I would agree with you. But it
would be impossible for us to come up with $300 a month to cover me. We
would be sacrificing any ability to save money for emergencies, and
would most definitely be cutting into our grocery budget. As a mother,
my responsibility is to my children and family. My sons remain well fed
and insured. I also have the responsibility of taking care of myself.
Fortunately, I am a healthy woman. Even so, my lack of insurance is a
constant source of stress.
I am tired of the tactics insurance companies use to make quality
coverage unaffordable. Tactics that include outrageous separate
deductibles for the common condition of pregnancy. I do not trust these
companies, and certainly do not believe that they will ever have the
best interests of patients at heart. I want an affordable public option
that will provide quality coverage and the assurance that out-of-pocket
costs will be reasonable and fair. Health insurance premiums should be
a part of every family's budget; however they should not be a crippling
part.
My family could live comfortably on my husband's salary if our
insurance premiums were reasonably proportionate to our income. We have
made many minor sacrifices in order for me to remain at home with our
children, however in this day and age, and in this great country I
should not have to sacrifice basic health care coverage as well.
Thank you for your time.
For the record, I would like to submit a few additional points.
As I said, affordability is a key. As the Congress works to merge
the House, HELP, and Senate Finance Committee bills, I hope you will
put yourself in the shoes of families like mine. We need a good health
insurance policy that is affordable and covers such life-events as
childbirth. I've looked at the ``comparison'' Web site of Kaiser Family
Foundation. I typed in our family's approximate situation and compared
the different bills' results.
The Web site does not allow me to enter our exact situation. So I
typed in a $35,000 gross income for a 30-year-old in a family of four
in a low-cost area of the country, not eligible for group coverage.
Your committee's HELP bill would cost us about $491 in annual premiums
and we would owe on our medical bills about 7 percent in co-pays. The
House bills would be about $1,185 in premiums, and 7 percent of bills
in co-pays. The Senate Finance Committee bill would be about $1,728 in
premiums and we'd pay about 20 percent of the bills in co-pays. The
House and the HELP proposals' limits on out-of-pocket, in-network costs
are lower than Senate Finance's. In a worst case situation, we could
owe about 39 percent of our total income under the Finance bill--and a
good chance of bankruptcy.
Please do as much as you can to move toward the best possible
levels of affordability and catastrophic coverage.
Providing help to working families such as mine will take more
money--or it will take more savings in the health sector. If the
Congressional Budget Office says that a public option saves money,
please include it in the new law. We need the extra competition. As I
said, there is almost no real competition in my State.
Also, I've heard friends complain about the fine print, loopholes,
and ``got 'cha' aspects of health insurance policies. I hope the final
law can retain the HELP and Senate Finance Committee provisions that
define medical and insurance terms so consumers can compare apples-to-
apples. I particularly like your idea of ``scenarios'' of what it would
cost to be treated for certain common conditions.
And I urge you to consider adding an idea I've heard that might
help save money. In whatever ``exchange'' or ``connector'' marketplace
established to help people shop, make sure that the consumer is told
not just the premium cost, but also the estimated annual total cost,
based on past medical history or on one's own estimate of one's health
condition--for example, ``good health, fair health, poor health.''
Consumers Union has some data that shows that when consumers can see an
estimate of their likely total cost, they make much better choices than
if they only have premium information available. And if they make
better insurance choices, they will need less subsidy help with
premiums, deductibles, and co-pays. Total estimated cost data will help
everyone win.
Senator Mikulski. Ms. Robertson.
STATEMENT OF PEGGY ROBERTSON, PATIENT/HEALTH CARE
CONSUMER, CENTENNIAL, CO
Ms. Robertson. Thank you for giving me this opportunity to
speak today. My name is Peggy Robertson. I live in Centennial,
CO. I have two boys, ages 10 and 3.
Shortly after my youngest son was born, my husband and I
began to research independent health insurance options because
our current policy was increasing in price every year. My
husband is self-employed and we are unable to get access to a
group policy. We applied with Golden Rule and I was denied
coverage based on having a Caesarian with Luke in 2006. I'm in
perfect health and I was shocked that Golden Rule would decline
my application.
I called Golden Rule and they said that if I would get
sterilized they would then be able to offer insurance to me. I
was shocked by their comments and I immediately contacted the
Colorado Division of Insurance to file a complaint. After
filing a complaint, I discovered that Golden Rule is allowed to
discriminate against women who have had a C-section. There was
nothing I could do.
I'd like to take a moment to read a couple of paragraphs
from their letter of denial:
``The plan you applied for is an association group
plan and it's medically underwritten. As a general
rule, our underwriting guidelines require that we issue
coverage with a rider excluding benefits for Caesarian
section delivery for 3 years. However, the Colorado
Division of Insurance no longer allows us to place that
rider. Without the rider, we have decided that we
cannot provide any coverage for the individual.
Unfortunately, we cannot collect sufficient premium to
offset the risk of paying for a repeat C-section
delivery during the first 3 years of coverage.
``In order to consider coverage without a rider, we
require that certain requirements be met. One
requirement is that some form of sterilization has
occurred since the Caesarian section delivery. Also,
women age 40 and over who had their last child 2 or
more years prior to applying for coverage will not
require a rider.
``Unfortunately, since you had not met either of these
requirements, it would have been necessary to place the
C-section rider.''
As a result, I then contacted International Caesarian
Awareness Network to see if they could help me share my story
and create change. They were able to do that and my story was
covered on the front page of the New York Times. I discovered
that in all but five States it is legal to discriminate against
women because of a previous Caesarian, either by denying
coverage, requiring sterilization, or charging significantly
higher premiums than would be paid by a woman without a
previous C-section.
My husband and I ended up accepting an insurance plan with
a high deductible that honestly could financially ruin us if
there was a family medical emergency. In addition, my youngest
son has been denied insurance coverage twice and we have had to
find alternative health insurance for him at a higher cost and
a higher deductible.
As a result of my C-section, we were unable to have a third
child. We attempted to get maternity insurance and discovered
that the max we could receive is $4,000, and in order to
receive that full pay we would have to have been insured by the
same company for 3 years. Also, once a woman has had a C-
section it is almost impossible to qualify for a vaginal birth
after Caesarian. As a result, most doctors would require me to
have another C-section with a third child, which is financially
impossible, much more expensive than $4,000, and therefore this
has limited our ability to have any more children.
Not only are women being denied coverage because of a
previous Caesarian, but they are also being denied the
opportunity to have a nonsurgical delivery with their next
pregnancy because of widespread policies that ban vaginal birth
after Caesarian.
Thank you.
[The prepared statement of Ms. Robertson follows:]
Prepared Statement of Peggy Robinson
My name is Peggy Robertson. I live in Centennial, CO. I have two
boys ages 10 and 3. Shortly after my youngest son was born, my husband
and I began to research independent health insurance options because
our current policy was increasing in price every year. My husband is
self-employed and we are unable to get access to a group policy.
We applied with Golden Rule and I was denied coverage based on
having a cesarean with Luke in 2006. I am in perfect health and I was
shocked that Golden Rule would decline my application. I called Golden
Rule and they said that if I would get sterilized, they would then be
able to offer insurance to me. I was shocked by their comments and
immediately contacted the Colorado Division of Insurance to file a
complaint. After filing a complaint, I discovered that Golden Rule is
allowed to discriminate against women who have had a C-section. There
was nothing I could do.
I contacted the International Cesarean Awareness Network to see if
they could help me share my story and create change. They were able to
do that and my story was covered on the front page of the New York
Times. I discovered that in all but five States, it is legal to
discriminate against women because of a previous cesarean, either by
denying coverage, requiring sterilization or charging significantly
higher premiums than would be paid by a woman without a previous C-
section. My husband and I ended up accepting an insurance plan with a
high deductible that honestly could financially ruin us if there was a
family medical emergency. In addition, my youngest son has been denied
insurance coverage twice and we have had to find alternative health
insurance for him at a higher cost and a higher deductible.
As a result of my C-section, we were unable to have a third child.
We attempted to get maternity insurance and discovered that the max we
could receive is $4,000, and in order to receive that full pay, we
would have to have been insured by the same company for 3 years. Also,
once a woman has had a C-section, it is almost impossible to qualify
for a VBAC. As a result, most doctors would require me to have another
C-section with a third child, which is financially impossible, much
more expensive than $4,000, and therefore, this has limited our ability
to have any more children.
Not only are women being denied coverage because of a previous
cesarean but they are also being denied the opportunity to have a non-
surgical delivery with their next pregnancy because of widespread
policies that ban vaginal birth after cesarean.
Senator Mikulski. Ms. Ignagni.
STATEMENT OF KAREN IGNAGNI, PRESIDENT AND CEO, AMERICA'S HEALTH
INSURANCE PLANS, WASHINGTON, DC
Ms. Ignagni. Thank you, Madam Chairwoman. We appreciate the
opportunity to testify today.
In listening to the testimony of Ms. Robertson and Ms.
Buchanan, our members are committed to policies that would get
reform accomplished this year and would include a massive
overhaul of the way the individual market works. We've
testified to that before this committee. We remain committed to
it, and specifically we are committed to policies where
everyone gets covered, no one loses it, they would be portable,
and no preexisting condition exclusions would be allowed.
We've also had considerable focus in our membership on the
needs of women. We've supported and advocated for reform that
gives women equal health care for equal premiums. We also
support the important preventive services that this committee
has worked on and we believe they are very important to the
needs of women and maintaining their health.
We've provided research to this committee and other
committees on what it will take to accomplish this objective,
to achieve these goals in the individual market, and that is,
encapsulating it, everyone participating in the system.
I wanted to take this opportunity, since there has been
considerable discussion this week about a recent report we
issued from the PricewaterhouseCoopers Group and the reason we
issued that report when we did. In its markup, the Senate
Finance Committee moved away from the policy that would have
everybody participate in the system. At that time we raised
concerns about that moving away and we sent a letter suggesting
it would lead to significant increases in costs, which no one
wants.
On September 29th, we asked PWC to look at this issue
because in our own data we detected alarming trends by way of
potential cost increases associated with this change. We
received PWC's report Saturday, as in this Saturday several
days ago, evening and we shared it with our members on Sunday.
At that time the Senate was expected to take up health reform
next week.
The message of the study, which has been confirmed by
another independent report released yesterday, is that costs
are going to go up for individuals and working families if we
don't have everyone participate.
So we are in the same place, Madam Chairwoman, that we were
when we came to this committee in March. We strongly support
health care reform. We strongly support insurance market
reforms that a number of the panelists and the members of the
committee have spoken to. But we want it to work.
During the summer we worked hard as part of a joint effort
to bend the cost curve. If Congress were to commit to system-
wide cost containment, then the costs would go down, not up.
Madam Chairwoman, you challenged us specifically back in the
winter to commit to administrative simplification. We have
taken that very seriously. That is part of our efforts to bend
the cost curve. That's what we control, that's where we
contribute. I'm pleased to tell you that our members have
supported mandatory requirements that we get this done. We've
worked with doctors and hospitals. We're pleased to stand
behind that support and we will continue to do so.
But if we're going to bend the curve, which would take
pressure off purchasers, consumers, and the government, we need
to have everyone participate and all stakeholders need to
participate.
Our industry has committed to reforms that would address
the important issues we are hearing about today. We have
proposed no longer basing premiums on gender. We agree with
that. We also have advocated for States to adopt legislation so
that no one is denied coverage for domestic abuse. We agree
with that. We've supported eliminating preexisting condition
exclusions entirely. We agree with that. And we have proposed
an essential benefit package that provides coverage for vital
health care services, such as prevention and maternity
coverage.
Our industry is committed to making these experiences that
we've heard about today a thing of the past. It's the right
thing to do and we stand behind that commitment.
Thank you very much for the opportunity to testify.
[The prepared statement of Ms. Ignagni follows:]
Prepared Statement of Karen Ignagni
i. introduction
Chairman Harkin, Ranking Member Enzi and members of the committee,
I am Karen Ignagni, President and CEO of America's Health Insurance
Plans (AHIP), which is the national association representing
approximately 1,300 health insurance plans that provide coverage to
more than 200 million Americans. Our members offer a broad range of
health insurance products in the commercial marketplace and also have
demonstrated a strong commitment to participation in public programs.
We thank the committee for holding this important hearing, and we
appreciate this opportunity to testify. Our members are strongly
committed to meeting the health care needs of women, and we fully
support efforts to ensure that women are treated fairly and equitably
under our Nation's health care system. Our testimony today will focus
on three key areas:
AHIP's support for comprehensive health reforms that would
correct flaws in the current system and address the coverage needs of
women;
innovative programs our members have implemented to
improve health care for the women they serve; and
research findings showing that private health insurance
plans are enhancing the health and well-being of female enrollees.
ii. fixing the health insurance market to address women's health
concerns
AHIP's members have proposed far-reaching health insurance reforms.
Our proposals directly confront the reality that the individual health
insurance market, as currently structured, is seriously flawed and
needs to be fundamentally overhauled.
To solve this problem, it is important to first recognize that
insurance works only when people pay into the system both when they are
healthy and when they are sick. This is not the case under the current
system, since coverage is purchased on a voluntary basis and many young
and healthy people choose to go without coverage. Within this flawed
system, the adoption of preexisting condition exclusions and waiting
periods for new enrollees is an approach that plans are forced to use
to keep coverage affordable for those people who maintain coverage on
an ongoing basis. By adopting these practices, health insurance plans
are working to keep costs as low as possible for as many people as
possible--while also recognizing very clearly that major changes are
needed to replace this inadequate system with a reformed system that
works well for all Americans.
Our members are aggressively promoting major reforms to accomplish
this goal. The foundation of our proposal would eliminate rating based
on gender and health status and, additionally, provide guaranteed
coverage for preexisting conditions in the individual market.
Prohibiting premium variation based on gender is a critically important
step toward providing security and peace of mind to women and assuring
that they receive equal health care for equal premiums. These reforms,
when combined with a personal coverage requirement and premium
assistance for low-income and moderate-income individuals and families,
will ensure that no one--regardless of their gender, health status, or
medical history--falls through the cracks of the U.S. health care
system.
Establishing an enforceable coverage requirement is particularly
important to the success of the insurance market reforms we are
proposing. If the individual coverage requirement provides inadequate
incentives to get everyone covered, individuals and families who are
covered in the individual market are likely to experience unintended
consequences similar to those experienced in several States where
insurance market reforms were enacted in the absence of universal
coverage in the 1990s. A Milliman Inc. report \1\ released by AHIP in
September 2007 examined the experience in the eight States that enacted
various forms of community rating and guarantee issue laws in the
1990s, without establishing an individual coverage requirement. A
significant number of individuals responded to these reforms by
deferring coverage until after they encountered health problems and, as
a result, the Milliman report found that these States experienced
higher premiums for those with insurance, saw reduced enrollment in
individual health insurance coverage, and had no significant decrease
in the number of uninsured.
---------------------------------------------------------------------------
\1\ The Impact of Guaranteed Issue and Community Rating Reforms on
Individual Insurance Markets, Milliman, Inc., August 2007.
---------------------------------------------------------------------------
Other organizations--including the Commonwealth Fund \2\ and the
Urban Institute \3\--also have recognized the need, in the context of
comprehensive health reform, to bring everyone into the system with an
individual coverage requirement.
---------------------------------------------------------------------------
\2\ The Path to a High Performance U.S. Health System, Commonwealth
Fund, February 2009.
\3\ The Individual Mandate--An Affordable and Fair Approach to
Achieving Universal Coverage, New England Journal of Medicine, Linda
Blumberg, Ph.D. and John Holahan, Ph.D., June 2009.
---------------------------------------------------------------------------
More recently, AHIP commissioned a report \4\ by
PricewaterhouseCoopers because of our concerns about the workability of
the current legislative proposals. We wanted outside verification of
the trends we were seeing in our own analyses, suggesting that the
reform construct in the Senate Finance Committee bill could lead to
alarming unintended consequences during implementation. This study
confirms that the current legislation will make coverage less
affordable for individuals, families and employers, and make it harder
to get all Americans covered. It shows that costs will go up even
faster than they would under the current system.
---------------------------------------------------------------------------
\4\ Potential Impact of Health Reform on the Cost of Private Health
Insurance Coverage, PricewaterhouseCoopers, October 2009.
---------------------------------------------------------------------------
Health insurance plans are strongly committed to working with
Congress to avoid this outcome. Our Board of Directors has endorsed
major proposals for expanding coverage, improving quality, and reducing
the growth rate of health care spending. These reforms--which we
outlined in our testimony for the committee's March 24 hearing--build
upon the strengths of the current system and recognize that both the
private sector and public programs have a role to play in meeting these
challenges.
Health insurance plans also are contributing to the reform debate
through a system-wide simplification effort to streamline
administrative procedures and achieve cost efficiencies for physicians
and hospitals, and by committing to help fund a reinsurance mechanism
during the transition to the market reforms. Together, these
contributions will decrease costs across the health care system, reduce
paperwork and duplication, and ensure that everyone can obtain high
quality coverage that is portable across the entire system.
Another critically important priority in the health reform debate
is improving access to preventive services, which are particularly
important for women. We support pending legislation that would
eliminate cost-sharing for preventive services rated ``A'' or ``B'' by
the U.S. Preventive Services Task Force (USPSTF) and for immunizations
recommended by the Advisory Committee on Immunization Practices (ACIP).
Providing first dollar coverage of proven preventive services is an
important strategy for keeping people healthy, detecting diseases at an
early stage, and avoiding preventable illnesses.
Our members have been pro-active in designing wellness and
prevention programs that promote healthier lifestyles and preventive
screenings, identify and monitor patients at high risk for certain
conditions, help ensure early diagnosis and treatment, and address the
unique needs and circumstances of women. These programs help to improve
quality of care and should be supported by the health reform process,
including the flexibility for plans to offer premium discounts based on
an individual's or an employee's participation in wellness programs.
iii. health plan innovations addressing women's health care needs
Health insurance plans, in addition to supporting health reform,
have been very active in developing innovative programs to improve
health care quality and health outcomes for women. These programs--
including several that we discuss below--focus on a wide range of
women's priorities and health care needs.
Geisinger Health Plan's Health Management Program for Osteoporosis
Geisinger Health Plan has implemented a program that analyzes
claims to identify patients whose medical histories and demographic
characteristics place them at risk of the disease, as well as those who
have a history of bone fractures. Under this program, registered nurse
case managers contact members at risk by phone or arrange office visits
to provide them with key information about osteoporosis prevention and
treatment. During these phone calls and meetings, case managers explain
risk factors for osteoporosis, discuss ways to prevent the condition,
and discuss the benefits of bone mineral density testing and
medications for osteoporosis.
When Geisinger determines that patients' age and health profiles
place them at high risk of osteoporosis, case management nurses review
the patients' prescriptions to avoid use of medications that could
increase the risk of falls, and they follow up with physicians as
needed to identify safer alternatives. Case managers work with pharmacy
assistance programs as needed to help low-income members obtain needed
osteoporosis medications. They may coordinate with Area Agencies on
Aging to conduct home safety inspections to remove items that could
lead to falls, and they can help arrange for transportation to doctor
visits. Besides working with patients on an ongoing basis, Geisinger's
case managers maintain regular contact with primary care physician
offices by phone and e-mail and in person to discuss the needs of
members with osteoporosis and help ensure that they receive recommended
care.
In 2009, 21 percent of Geisinger members age 65 and older are
enrolled in the health plan's osteoporosis health management program.
The percent of women age 67 or older with histories of bone fracture
who had either undergone bone mineral density testing or had taken
osteoporosis prevention or treatment medications rose by 9.4 percent
from 2008 to 2009.
Kaiser Permanente's Domestic Violence Prevention Program
On October 10, Kaiser Permanente and Dr. Brigid McCaw received a
national award from the Family Violence Prevention Fund for creating
and implementing an innovative and comprehensive approach to domestic
violence prevention.
This innovative program by Kaiser Permanente uses health education
materials, posters, flyers, and other information to encourage people
to speak up about domestic violence. Under this program, clinicians
receive training so they are comfortable raising this issue, providing
a caring response, referring patients to on-site domestic violence
services, and offering information about community resources.
The program is enhanced by Kaiser Permanente HealthConnect, which
enables the organization's more than 14,000 physicians to
electronically access the medical records of members nationwide. It
includes tools that make it easier for physicians to identify victims
of domestic violence, provide a consistent caring response based on
clinical practice recommendations, and make referrals to other Kaiser
Perma-
nente services and community resources.
Passport Health Plan's ``Tiny Tot'' Program for Healthy Pregnancies
Passport Health Plan has created a ``Tiny Tot'' program to help
mothers with preterm newborn babies to ensure a healthy transition from
the hospital to the home. Under this program, a registered nurse is
assigned to focus on the welfare of the newborn and to work as a
liaison between the family and members of the infant's health care
team, including neonatologists, pediatricians, neonatal intensive care
unit nurses, and home care providers. The nurse helps the family with
the paperwork for obtaining any necessary medical equipment, such as
ventilators, and with the logistics for getting to appointments with
specialists.
The program also includes a strong focus on educating new mothers
about infant care and the importance of creating a healthy home
environment. The program's goals are to:
decrease the average length of stay in the hospital;
decrease or prevent hospital re-admissions and emergency
room visits within 30 days of discharge;
increase the percentage of members who follow up with
their primary care physician within 30 days of discharge;
identify newborns in need of ongoing case management
services; and
coordinate discharge needs.
Enrollees participating in the ``Tiny Tot'' program have a 98
percent compliance rate in obtaining a newborn screen within the first
30 days. Also, since the program began in 2001, hospital re-admission
rates for preterm babies have decreased in the range of 1 to 4
percentage points.
This program--and the CIGNA program discussed below--are
particularly important, given that the rate of preterm births in the
United States has increased by 18 percent since 1990, according to the
March of Dimes. Babies who survive a premature birth face the risk of
serious lifelong health problems including learning disabilities,
cerebral palsy, blindness, hearing loss, and other chronic conditions
such as asthma. Also, the health care costs associated with a preterm
birth typically are 12 times as much as those for a full term, healthy
birth.
CIGNA's Healthy Pregnancies, Healthy Babies Program
To address the rise in preterm births, many of which are
preventable, CIGNA implemented its Healthy Pregnancies, Healthy Babies
program in 2006 to provide educational and care management services to
women who are pregnant or considering pregnancy.
Participants in the program undergo an initial risk assessment and
routine follow-up assessments throughout their pregnancy. Based on
these assessments, participants will receive appropriate prenatal
education and care management, and those considered high risk will be
assigned to a Specialty Case Management Nurse. Clinical assessments,
risk stratification and history are managed through a single tool so
that any member of the care team can speak to a participant
knowledgably about her condition. Participants receive one-on-one
counseling and support from a health coach, who can help the mother-to-
be manage the physical and emotional demands of pregnancy.
Because early intervention can help prevent prematurity and other
poor pregnancy outcomes, the program offers a tiered incentive that is
higher for women who enroll early in their pregnancies. To help assure
that pregnant members participate actively in the program, payment of
the incentive is contingent on program completion. CIGNA also offers
free tobacco cessation programs, as there is indisputable evidence that
links smoking with preterm birth and low-birth weight babies. Extra
dental care also is part of the program, as pregnancy can affect teeth
and gums, and infections and other oral health problems can lead to
preterm birth.
More than 90 percent of the women who enroll in the program
complete it, and more than 97 percent report a high level of
satisfaction with their experience in the program. Improved outcomes
for mothers and babies have led to savings of more than $6,000 per
pregnancy for participants of the program.
Centene Corporation's CONNECTIONS Plus Program
A program by Centene Corporation, known as CONNECTIONS Plus, offers
free cell phones to Medicaid members who do not have safe, reliable
access to land line phones. As of last year, the health plan had
provided cell phone service to 160 pregnant women since the program's
inception in 2007. Program participants use the cell phones to call
their doctors, case managers, 911, and the health plan nurse line when
they need help, and they can speak regularly with nurse case managers
affiliated with Centene's disease management programs.
Under this program, cell phones can be customized to member needs
and may include numbers for transportation services, specialty pharmacy
services, housing and shelter, parenting support, emergency crisis
numbers, counseling, special needs services, food pantries, utility
assistance, clothing banks, parenting support, and family support.
High-risk pregnant women are allowed to keep their cell phones for a
transition period (about 6 weeks) following their babies' birth.
There is strong evidence that low-income women are at increased
risk for preterm births. The average gestational age at delivery for
the babies of pregnant women who have participated in the Centene
Corporation program since 2007 is 37.79 weeks, which is well within the
normal range.
Keystone Mercy's Healthy Ministry Program for Women
For more than 9 years, Keystone Mercy Health Plan has offered the
Health Ministry Program for Women, a faith-based health education and
awareness program to reduce health disparities among minority women.
The program helps women incorporate positive health behaviors into
everyday life to prevent, reduce, and reverse chronic diseases and
stress. By partnering with and bringing local health care providers to
churches, synagogues, and mosques, the Health Ministry Program provides
women with a safe and supportive setting in which to learn about their
health.
The program's goals are to:
educate women and their families about the importance of
prevention and early detection of disease through community-based
partnerships;
promote regular health screenings and check-ups to
identify and target women at risk;
increase participants' knowledge of stress triggers and
stress management techniques; and
empower women to be their own health advocates by knowing
the risks and warning signs of chronic diseases.
As part of the Health Ministry program, Keystone has partnered with
six Philadelphia-area churches for the past 3 years on an initiative
called the Forty-Day Journey. The initiative emphasizes nutrition,
exercise, water intake, and medication compliance. It includes
education on topics such as healthy cooking, and it features a Gospel
aerobics class and walking clubs.
Approximately 2,500 people, including 825 Keystone Mercy Members,
participated in the Forty-Day Journey from 2006 to 2008. Among program
participants with diabetes, Keystone measured the following
improvements over 2 years:
A nearly 20 percent drop in triglyceride levels;
A 22 percent decline in LDL, or bad cholesterol, overall,
and a 31 percent decline for people with Type 1 diabetes;
A 17 percent reduction in blood sugar levels;
A 4.6 percent reduction in weight overall, and a 3 percent
decline for people with Type 1 diabetes.
Program participants reported reductions in pain and improvements
in mobility and flexibility. They also said that their overall mood had
improved and hope for the future had increased since participating in
the program. In 2008, the Health Ministry Program won the ``Recognizing
Innovation in Multicultural Health Care Award'' from the National
Committee for Quality Assurance (NCQA).
Group Health Cooperative's Teen Pregnancy and Parenting Clinic
Group Health Cooperative has established a Teen Pregnancy and
Parenting Clinic that provides education and support to help pregnant
teens avoid risky behaviors--such as smoking, alcohol, and recreational
drug use--that can lead to premature birth, low-birth weight, and
cognitive impairments. Program participants range in age from 13 to 25.
Two family physicians, along with family practice residents from
Group Health's Family Medicine Residency program, provide care at the
clinic, including antepartum care, delivery, postpartum care, primary
care, and pediatric follow-up. The clinic team also includes a
registered nurse, a social worker, a nutritionist, a representative
from the U.S. Department of Agriculture's Special Supplemental
Nutrition Program for Women, Infants and Children (the WIC program),
and a health educator. The nurse meets with patients during every
visit, helps assess their needs, and coordinates care with other team
members. The social worker addresses psychosocial issues and helps
program participants obtain community resources such as housing and
transportation. The nutritionist helps teens create a diet appropriate
for pregnancy; the WIC provider helps participants obtain vouchers for
free groceries; and the health educator teaches parenting classes.
The clinic provides care to approximately 50 teens and their
children each year. Participating teens visit the clinic every 1 to 3
weeks throughout their pregnancy and have follow-up visits for 2 years
after delivery. Their children receive services through the clinic for
up to 5 years. Health outcomes among program participants have exceeded
those achieved among comparable populations served by Seattle-area
community health centers.
Since the clinic's opening in 1990, program staff have delivered
736 babies and the percent of low-birth weight babies (those less than
5 pounds) has been 6.7 percent, compared to a national rate of 8.3
percent.
Prevention and Wellness Initiatives
In a recent AHIP report \5\ entitled ``Innovations in Prevention,
Wellness, and Risk Reduction,'' we outline case studies of health
insurance plans that are working with other stakeholders to create
healthier workplaces, schools, and communities, help families make
better choices about diet and physical activity, and overcome economic,
social, and cultural barriers to the adoption of preventive practices
and healthier lifestyles. This report highlights a wide range of health
plan initiatives that are combining personal health assessments, health
coaching, changes in the work environment, and lifestyle incentives to
help employers and their employees tackle health risks that lead to
illness, absenteeism, lost productivity, and higher health care costs.
---------------------------------------------------------------------------
\5\ Innovations in Prevention, Wellness, and Risk Reduction, AHIP,
2008.
---------------------------------------------------------------------------
iv. research findings show women benefit from private sector
innovations by medicare advantage plans
AHIP recently released a study \6\ showing that Medicare Advantage
enrollees spent fewer days in the hospital, were subject to fewer
hospital re-admissions, and were less likely to have ``potentially
avoidable'' admissions for common conditions examined by the study.
While this study focused broadly on both women and men, the findings
indicate that women are particularly well-served by participating in
private health plans offered through the Medicare Advantage program.
---------------------------------------------------------------------------
\6\ A Preliminary Comparison of Utilization Measures Among Diabetes
and Heart Disease Patients in Eight Regional Medicare Advantage Plans
and Medicare Fee-for-Service in the Same Service Areas, AHIP, revised
September 2009.
---------------------------------------------------------------------------
The study's findings demonstrate that the innovative programs
developed by Medicare Advantage plans--which place strong emphasis on
preventive health care services that detect diseases at an early stage
and disease management programs for seniors with chronic illnesses--are
working to help keep patients out of the hospital and avoid potentially
harmful complications.
The median scores for the eight plans included in this study show
that Medicare Advantage plans improved health care for women by:
reducing emergency room visits by 35 percent;
reducing hospital re-admissions by 50 percent;
reducing potentially avoidable hospital admissions by 16
percent;
reducing inpatient hospital days by 18 percent; and
increasing office visits (e.g., for primary and preventive
care) by 20 percent.
A related AHIP study \7\ shows that women enrolled in Medicare
Advantage spent fewer days in the hospital, were subject to fewer
hospital re-admissions, and were less likely to have potentially
avoidable admissions, for common conditions ranging from uncontrolled
diabetes to dehydration. This study analyzed statewide datasets on
hospital admissions in California and Nevada compiled by the AHRQ. The
unique data in these States allows for direct comparisons of
utilization rates among enrollees in Medicare Advantage plans and in
FFS Medicare. The female-specific data for this study indicate that:
---------------------------------------------------------------------------
\7\ Reductions in Hospital Days, Re-Admissions, and Potentially
Avoidable Admissions Among Medicare Advantage Enrollees in California
and Nevada, 2006, AHIP, September 15, 2009.
Women Medicare Advantage beneficiaries in California spent
30 percent fewer days in the hospital than those with FFS Medicare, and
in Nevada, women in Medicare Advantage plans spent 26 percent fewer
days in the hospital.
Women Medicare Advantage enrollees were re-admitted to the
hospital in the same quarter for the same condition 16 percent less
often in California and 33 percent less often in Nevada, compared to
FFS Medicare.
In both States, women enrolled in Medicare Advantage plans
were less likely--by margins of 8 percent in California and 9 percent
in Nevada--than those in FFS Medicare to be admitted to the hospital
for conditions described by AHRQ as ``potentially avoidable,'' such as
dehydration, urinary tract infection, or uncontrolled diabetes.
These findings demonstrate that by reducing the need for
hospitalizations and emergency room care, health insurance plans are
not only improving the health and well-being of their female
enrollees--but also achieving greater efficiencies and cost savings.
In both AHIP studies, utilization rates were calculated on a risk-
adjusted basis. Risk scores for Medicare Advantage and Medicare FFS
enrollees were based on age, sex, and health status.
v. conclusion
Thank you for this opportunity to testify on these important
women's health issues. We look forward to continuing to work with
committee members to advance meaningful health reforms to expand
coverage, improve quality, and slow the growth rate of health care
spending.
Senator Mikulski. The way we're going to proceed is I'll be
the wrap-up questioner. I'm going to turn to Senator Merkley
from the Democratic side, then to Senator Burr, and then I'll
be the wrap-up. I know time's moving along and, Senator, you
were here. Senator Merkley, you will go first. Then we'll turn
to Senator Burr and then I'll be the wrap-up.
Statement of Senator Merkley
Senator Merkley. Thank you very much, Madam Chair.
Ms. Ignagni, I wanted to ask you a little bit about your
testimony. You noted your members are strongly committed to
meeting health care needs of women and support efforts to
ensure women are treated fairly and equitably. But AHIP has
supported a 5 to 1 rating band for older Americans, which is in
the Finance Committee bill, meaning that older Americans would
be charged five times the cost to their younger counterparts.
The HELP bill has a 2 to 1 rating band, and a higher rating
band would put a disproportionate burden on older women, many
of whom outlive men. I was wondering if you could just address
and explore that point.
Ms. Ignagni. Yes, sir. I appreciate the question and I'm
happy to clarify exactly where we are. This is a question about
how to equitably distribute costs. I want to make it very
clear, in supporting the rating bands that we have we are not
insensitive to the needs of older workers. What we have
proposed is a rating system that would lighten the load on Ms.
Robertson and Ms. Buchanan in terms of where they are in the
age cohorts.
At the same time, we have not ignored older workers. What
we have suggested is a special targeted subsidy that would
decrease the cost and the burden for individuals in the 55 to
65 cohort, so that we wouldn't have to impose--if you go to two
to one, it means that individuals and women at the lowest age
cohorts would face disproportionately higher costs.
I can tell you what that means very specifically. Someone
in the 30 to 34 age cohort would face an increase of 38 percent
compared to where they would be in the 5 to 1 category. We have
tried to be very thoughtful about commenting both how to
distribute the cost equitably, not to put too much pressure on
younger families, but at the same time also responsibly add a
suggestion on what to be done for older workers.
Senator Merkley. I thank you for your comment. I just note
that it remains a concern for this Senator.
Ms. Ignagni. Yes, sir.
Senator Merkley. Ms. Buchanan, to clarify, were you saying
that your insurance company would not cover a vaginal birth
after you had had a Caesarian and that that is a common
practice in the industry?
Ms. Buchanan. That's very common practice.
Senator Merkley. I just wonder if any members of the panel
can comment on that and how we might tackle that problem.
Ms. Ignagni. Would you like me to comment, Senator? I'd be
happy to.
Senator Merkley. That would be great.
Ms. Ignagni. We have spent a great deal of time looking at
the individual market. Approximately 18 million people are
covered in the individual market, as you know. We believe that
having everyone participate would allow any type of preexisting
condition requirements to end. We support that. We think it's
the right thing to do. We do not think there should be any
differentiation in terms of gender payments. We support that.
And we don't believe that people should be paying according to
their health status.
Senator Merkley. So this type of requirement would be
eliminated as far as you're concerned?
Ms. Ignagni. Yes, sir.
Senator Merkley. Very good.
Ms. Furchtgott-Roth. The reason it's originated, if I might
add, the reason it's originated is because of the lawsuits and
the vast amounts of malpractice insurance associated with
obstetrics. Obstetricians pay some of the highest malpractice
premiums in the Nation. There's a big chance of being sued, and
that's why it's regarded as safer to have a Caesarian, because
that gets the baby out right away. If there were malpractice
reforms accompanied by the health insurance, then these kinds
of problems could be diminished.
Senator Merkley. Mr. Guest, I wanted to turn to you for a
moment. In your testimony you describe ways to help consumers
make apples to apples comparisons of health plans and suggest
that insurers explore ways to help consumers gauge their
estimated annual total cost. Can you elaborate on how that sort
of consumer-friendly information could be presented?
Mr. Guest. Well, just in general, it covers a variety of
things. I'll give you one example of something Consumer Reports
is doing and then I'll also give you a longer answer for the
record in terms of the very specific ways that one can look at
the total, as opposed to just the premium. We have something
called Consumer Reports Best Buy Drugs, where we've worked with
a consortium of researchers looking at clinical evidence,
researchers from 15, 16 States, where we have identified drugs
that are equally effective, equally safe, and we've overlaid
that with cost information, with price information. So we're
saving consumers in some cases thousands, $500, $1,000, more
than $2,000 a month. That's just one kind of information.
But more generally, I think what would be really important
is, also as a way to reduce costs and improve quality, we have
been engaged in an effort for requiring hospitals to disclose
their hospital-acquired infection rates. Now 26 States have
laws requiring that. In Senator Casey's State of Pennsylvania,
what they've shown, what they've found, is with the public
disclosure of those rates it puts pressure on hospitals to do a
better job, it enables consumers to make choices of where they
may want to go for procedures in a hospital, and infection
rates have come down.
Whether it's infection rates, whether it's other adverse
events, there's a variety of things around quality of care as
well as cost that can help to make informed decisions.
Senator Merkley. Thank you very much. My time is up. Thank
you very much as a panel for your testimony. Oregon is one of
the States that has banned gender discrimination. I think it's
so important in health care reform that we have fairness for
women across our entire Nation.
Thank you.
Senator Mikulski. Senator Burr.
I'd like to comment that Senator Burr and I are the chair
and the ranking member on this committee and have worked a lot
on public health initiatives. Right now we're focusing on
insurance reform, but because this is the HELP Committee and we
don't have jurisdiction over the payment system, there's a lot
we feel we need to do in terms of public health and issues
around the management of chronic illness--the prevention of
diabetes, heart disease. Senator Burr has been a real leader
for these issues, and I thank him for his comity and insights
on so many things.
Senator Burr.
Senator Burr. Thank you, Madam Chairman.
I would ask of the chair unanimous consent to enter into
the record a Washington Post article that is entitled
``Malpractice Premiums, Rate of C-Sections Rise Together.'' I
think that highlights for all of our witnesses as well as the
members that there's a direct correlation here, and that if you
want to have true reform then you've got to reform all aspects.
You can't leave the tort challenges unchecked if you want to
address the concerns of Caesarian birth.
The chair referenced earlier to the report, Ms.
Greenberger, about battered women and pointing out eight
States. Now, I've had an opportunity to look at the report and
from what I can gather from the report you relied heavily on
the Women's Law Project and Pennsylvania Coalition Against
Domestic Violence that was published in 2002 for a lot of the
data that you put into your report.
I guess my question is this. Did your staff go back to
North Carolina to see if any of these things were accurate for
North Carolina today?
Ms. Greenberger. Yes, Senator, we did, and we know that the
issue of domestic violence as a preexisting condition can
manifest itself in a number of different ways. It can be that
an insurance commissioner----
Senator Burr. Did your staff find specific cases where
people had been denied access because of domestic violence?
Ms. Greenberger. That's a very fair question, and what we
know--we know that this has come up in a conversation with
insurance commissioner staff in North Carolina--is specifically
that women are being denied across the country.
Senator Burr. Ms. Greenberger, let me address North
Carolina specifically. I'll read a letter from my insurance
commissioner, Wayne Goodwin, and I would ask the chair
unanimous consent to put into the record his letter to me in
its entirety, and I'll just read a couple of sections:
``In North Carolina if a company or policy wants to
exclude something, they must declare it in an
application by asking the applicant directly about the
exclusion. Because exclusions are listed on the
application form and the department reviews and
approves the forms, we would know if a company tried to
consider domestic violence as a preexisting condition.
``My department--we are unaware of any company or
forms that have asked to exclude domestic violence as a
preexisting condition. If they did, we would have
denied it. My department has been unable to find a
single example of a company asking an applicant if they
have been a victim of domestic violence or a consumer
complaint about being asked for this insurance
purposes.
``However, the issue is far too important to leave
any possibility that it could happen. So to create
further protections, I have filed an administrative
rule for adoption in the North Carolina Administrative
Code. This is the most effective way to address these
concerns and add to our insurance regulations.''
Again, Madam Chairwoman, I would ask that that be included
into the record.
They say there's not been an example of it.
[Editor's Note: The letter referred to may be found in
additional material.]
Ms. Greenberger. If I could answer, Senator. First of all,
I'm very glad to hear the insurance commissioner recognizing
that the most effective protection is to have an explicit
protection. But if I could get back to your question about the
specific examples, they manifest themselves in many different
ways. For example, if a woman ends up in an emergency room with
cuts, bruises, broken arms, black eyes, typical injuries that
result from domestic violence, we know of instances where women
are being denied insurance coverage and neither the insurance
company----
Senator Burr. Ms. Greenberger, my question is specifically
on North Carolina----
Ms. Greenberger. I'm trying to answer it specifically.
Senator Burr. And the insurance commissioner tells me: We
haven't had a case, we haven't had anybody.
Ms. Greenberger. Well, I'm trying to explain. First, I
think it's great that he is now explicitly having a rule,
which, as our report pointed out, didn't exist before. That's
really excellent.
Second, because of the way insurance companies deal with
this issue in particular, they will often deny the coverage of
victims and survivors of domestic violence without saying that
that's the reason. So it's difficult.
Senator Burr. Ms. Greenberger, I'm just going by your
report.
Ms. Greenberger. And I'm trying to--you asked a question
about did we follow up and we did.
Senator Burr. I would encourage my colleagues--well, I
found out more information in my one phone call to North
Carolina than I think your report did. I would point out to my
colleagues the important part of the report is to read the end
notes. In the end notes it specifically says that you relied on
the 2002 study done in Pennsylvania for the data.
Now, my point would be this. If you read on, you would find
out that that 2002 study used early 1990 data to come up with
their report. The conclusion that I have is that the data
you've used to present this case is almost 20 years old, and I
just point out the fact that the chairwoman, having read the
report, referred to eight States that have, North Carolina
being included with it, denied for the purpose of battered
women. And in fact that's not what the State officials in North
Carolina say.
Ms. Greenberger. Actually, Senator, I really disagree with
what you said, because what that letter just said was that your
insurance commissioner has just changed the rules.
Senator Burr. No, ma'am. It says they have thoroughly
examined and had had no case where a company had had that on an
application and no complaint from a person.
Ms. Greenberger. Well, we talked in the report--yes,
Senator.
Senator Burr. My question is, can you present to us today a
person who this happened to in North Carolina?
Ms. Greenberger. Well, let me say two things. No. 1, the
first issue that you raised is are the eight States and the
District of Columbia current data and information? And the
answer is yes, and I believe that the insurance commissioner's
letter to you underscores that they are, that it is currently
accurate. We have checked and that number is currently
accurate. That's the first question you asked and I give you an
explicit answer.
Senator Burr. I think we'll agree to disagree, based upon
how I read the letter. But I'll leave it for my colleagues.
If the chair would indulge me for 2 additional minutes. I
did not mean to get caught up for that much time and I just
want to ask Ms. Ignagni something.
Senator Mikulski. Please, go ahead. Then we'll turn to
Senator Franken.
Senator Burr. I thank the chair.
Dr. Coburn and I introduced a bill and it focuses
specifically on wellness prevention and chronic disease
management. I believe these are essential features that we're
going to have to exercise to hold down health care costs. What
are some of the programs your member companies have put into
place to implement these three critical elements?
Ms. Ignagni. This is a very good question. We included,
Senator, in our testimony a list of very specific programs, but
let me highlight a couple of them for you. No. 1, we have quite
a great deal of work going on across the country in large plans
and small plans to intervene for women who may have very
problematic and high-risk pregnancies. Case management and
support services; there are a myriad of programs around the
country. They've won numerous awards and I think they're path-
breaking.
No. 2, for women who have high risks of certain chronic
illnesses, there are similar kinds of programs going on across
the country.
And No. 3, for women who need transportation services,
particularly low-income women, we've, particularly in our
Medicaid health plans, we've pioneered a range of very specific
services. You're right, wellness is important. Early
intervention is key and coordinate care is the difference
between having good health care and not having good health
care. And particularly for women, it's very, very important.
Senator Burr. Thank you.
I won't ask my second question. I'll just make a general
statement, because several of you referred to the expansion of
Medicaid where I think the Finance Committee bill expands the
coverage to 14 million Americans. I believe that through this
health care debate we have to be as concerned about expansion
of coverage as we are about access to care.
When you take 14 million Americans and you put them into a
health care system that MEDPAC says is denied care, or at least
the ability to be seen, by 40 percent of our health care
professionals, I think you have flunked on the access.
Hold our feet to the fire to come up with a way to provide
coverage to every American, not just shove them into a system
that today 40 percent of the health care professionals choose
not to see them based upon reimbursement. I think the expansion
of Medicaid is a flunk to what the President suggested, and
that's quality and access have to be linked. So I would point
that out.
The chair has shown tremendous indulgence and I thank you.
Senator Mikulski. Senator Bennet.
STATEMENT OF SENATOR BENNET
Senator Bennet. Madam Chair, thanks. I will be very brief
because I was late. We were on the floor talking about health
care.
I first wanted to just thank Peggy Robertson for being here
from my State and sharing her story, your story. It's a story I
know well and it's one of hundreds, if not thousands, of
stories that we've heard from across the State of Colorado,
millions of stories across the country, of people whom the
current system let down in a fundamental and profound way.
I wonder, Ms. Robertson, I'll just ask you first. As you
think about the health care reform that we're considering here
in Washington and imagine a world post the reform discussion,
what do you most hope to see as a consequence of the work that
we're doing?
Ms. Robertson. I think the big thing for me is that there
should be all options available to women. We shouldn't be
cornered into having to go a certain route. If I wanted a
vebac, I should be allowed to get one. If a Caesarian was a
better choice for me due to my health, that should be the route
I should be able to take. But I feel right now that my options
are very limited. So all options for women everywhere.
Senator Bennet. Well, I want to thank you again for being
here.
Ms. Robertson. Thank you.
Senator Bennet. Ms. Greenberger, just along those lines, I
just have one question for you, which is, why is gender rating
important to address in the affordability context?
Ms. Greenberger. Basically, it means for those who have to
go to the individual market, women who have less resources,
less earnings to begin with, being charged more, which makes
health care even more inaccessible for women. And second,
because of the combination of the higher premiums they are
charged because of gender rating and then the exclusion for
maternity-related care, which in the instance of Caesarian
sections can be even more expensive, and in some instances the
requirement of having to buy a rider. In others, the rider's
not even available. The expense can be so astronomical, or the
coverage even in the rider so limited, that it basically takes
away the ability to get insurance for maternity altogether, and
especially if there may be some additional costs involved, like
Caesarians.
When you combine the gender rating and then the exclusion,
and certainly the most obvious is the maternity-related
exclusion, which can be a problem even if you do not have to
face a Caesarian section, let alone if you do, it can be a very
toxic, literally toxic situation for women, and as a result
their families.
Senator Bennet. Thank you.
Madam Chair, I just wanted to say thank you to you for
holding this hearing and for your leadership throughout this
debate. Thank you.
Senator Mikulski.Thank you, Senator Bennet.
Well, this was an outstanding panel and I want to thank
everyone for participating and really putting a great deal of
thought into it.
I want to lead off my questioning with both Ms. Robertson
and Ms. Buchanan, who are young moms and who've obviously had
significant issues. Ms. Robertson, I'm going to ask a question
of you. I was a little taken aback by the letter you quoted, I
believe from the Golden Rule insurance company. You read that
letter. Are you saying that they said in that letter that you
should have a sterilization? Did I not hear you well?
Ms. Robertson. You heard that correctly. They said it in
the letter, and actually a woman said it to me on the phone
when I called as well.
Senator Mikulski. Well, on the phone's one thing, but a
written document is another.
Ms. Robertson. It's in the letter, yes.
Senator Mikulski. Could you read that?
Ms. Robertson. Sure.
``In order to consider coverage without a rider, we
require that certain requirements be met. One
requirement is that some form of sterilization has
occurred since the Caesarian section delivery.''
Senator Mikulski. In other words, that you would have to
document that you had had some form of sterilization.
Ms. Robertson. Yes.
Senator Mikulski. That gave me goose bumps.
Ms. Robertson. It was unbelievable.
Senator Mikulski. First of all, that phrase, just that
phrase, that concept, I mean, I found that bone-chilling. I
don't know how everybody else felt about it in the room, but it
put me on the edge of my chair. Knowing Ms. Ignagni the way I
do, I think she's not too crazy about hearing that either.
I think we need to, apart from reform, we need to follow
that up. No one, no one in the United States of America, in
order to get health insurance should ever, ever be coerced into
getting a sterilization. I find it offensive and I find it
morally repugnant. I intend to do something about that, whether
it's in this reform package or not. I just don't think it's our
country's--I do not think it's our moral and ethical framework.
Coerced? We rail against what we ask China to do about
coerced sterilizations. But I don't want to see it in our
American insurance industry. Just know I feel very strongly
about it.
Ms. Robertson. Thank you.
Senator Mikulski. The second thing is, let's go to the
young mothers. Are you both working or are you stay-at-home
moms? Ms. Robertson?
Ms. Robertson. I'm a stay-at-home mom.
Ms. Buchanan. I'm a stay-at-home mom as well.
Senator Mikulski. So essentially, your insurance comes
through your husbands, is that correct?
Ms. Robertson. We have independent health coverage, so it's
just an independent plan. We can't get coverage through his
work because he's self-employed.
Senator Mikulski. Your husband is self-employed and that's
part of that individual market.
Ms. Robertson. Exactly.
Senator Mikulski. You actually don't have anyone to bargain
for you, or you didn't have a major or even a minor employer to
be able to be an advocate for you.
Ms. Robertson. Not at all.
Senator Mikulski. Do you--what about you, Ms. Buchanan?
Ms. Buchanan. My husband is employed. He has a group
policy, but it turned out that the insurance, individual
market, was less than half the premium than what his group
policy offered.
Senator Mikulski. In Idaho the individual market was
cheaper?
Ms. Buchanan. Yes.
Senator Mikulski. Than the teachers' insurance?
Ms. Buchanan. It's divided by school district and it's a
small district.
Senator Mikulski. How many people are in Idaho?
Ms. Buchanan. I don't know. Over a million, I think.
Senator Mikulski. A million. Well, we're not going there.
Some of our best friends are from Idaho, Wyoming, Utah, et
cetera.
Now this issue in our health reform is about the health
exchange, where you could essentially go, as the President
says, to ``the shopping mall for insurance companies.'' Have
you had a chance to look at it? You're raising a family. I'm
not asking you to be policy wonks. But how did you find out
about your insurance? Here you're trying to raise a family,
balance your family budget, probably living far more frugally,
and your mandate to us would be to be frugal as well as working
on health reform.
Did you just spend hours on the phone trying to find
insurance?
Ms. Buchanan. When I found out that it would cost $760 a
month for myself and a baby per month, it was pretty jaw-
dropping, and I just got on the Internet and just looked. The
two companies----
Senator Mikulski. There were only two companies.
Ms. Buchanan. Yes, and the policies were basically
identical. It was just like, well----
Senator Mikulski. In a small State, in an exchange, you
only had two companies that were carriers in that State. But
you went on the Internet.
Ms. Buchanan. Yes.
Senator Mikulski. What about you, Ms. Robertson?
Ms. Robertson. We had an insurance broker come to our house
and discovered that there was nothing helpful there for him. He
couldn't help us. Then I also got on the Internet and I just
started filling out applications. And every year I end up
filling out more applications because my youngest son keeps
getting denied. It is just this ongoing thing that never ends.
Currently my youngest son is insured by Cover Colorado,
which insures people that can't get insurance anywhere else.
Senator Mikulski. I don't mean to be intrusive, but what is
the reason? Or if you're hesitant to say, that's OK.
Ms. Robertson. What's interesting is Cover Colorado
actually is supposed to insure people that are terminally ill.
There is nothing wrong with my son. The first time he was
denied for being what they call a breath-holder. When he gets
angry, he passes out, which is actually a common thing that
lots of toddlers do.
This year they told me to reapply because they wanted to
make sure he wasn't going to have a seizure due to being a
breath-holder. He of course never had one. I reapplied this
year and this year they said because he's in the lowest
percentile--he's short and he doesn't weigh a lot, which my
husband and I are both short, so of course he would be. But
he's now been declined for being small.
Senator Mikulski. Oh, boy, that's another sensitive one
with me.
Ms. Robertson. Yes.
Senator Mikulski. Don't even go there.
[Laughter.]
You and I are going to have to bond after this hearing.
But really, this is no laughing matter. But as you know, if
there was a one-stop shop that either of you could go to in
order to buy across State lines--a one-stop shop for you to
identify the coverage that best suited your family, both from
the standpoint of anticipated medical situation or pocketbook
issues, would that be of value to you?
Ms. Robertson. Most definitely.
Senator Mikulski. Ms. Buchanan?
Ms. Buchanan. Yes, as long as it was affordable.
Senator Mikulski. But that would be it. In other words, you
would be able to get a clear sense of what benefits are
available and how affordable they are.
Ms. Buchanan. Then one of my problems is I have continually
changed my son's policies as well because the premium keeps
going up, in an attempt to get the most for my money. I mean,
my 2-year-old has been on four different policies and my 9-
month-old has been on three different policies. It's confusing
and I just wouldn't want to have to keep doing that every time
the policies went up every year, trying to reevaluate how much
we had to spend and how much we were going to get.
Senator Mikulski. Wow. You are your own broker in some
ways, I understand.
I'm going to go to Ms. Greenberger--I know our time is
getting short, I'd love to ask everybody--and then Ms. Roth,
and then you, Ms. Ignagni, and then we're going to close. We're
having a meeting on health care, surprise, surprise.
Ms. Greenberger, you wanted to say something about older
women. Was there a particular point that you wanted to make?
Ms. Greenberger. In particular that the savings need to be
made in the system, everybody recognizes. I think with respect
to older women who are covered either through Medicare or
Medicaid, one of the things that is of importance to us is that
there are some very important innovative care models in the
health care reform proposals, particularly in the HELP bill,
that could provide much better care for older women than they
currently have right now, and all patients that are covered.
There's a patient-centered medical homes provision, for
example, that could mean improved care. We see the potential of
health care reform as actually helping older women and older
men who are covered under Medicare right now.
Senator Mikulski. Well, the concept of the medical home, of
course, was in the Baucus white paper, and it's something
Senator Harkin and I picked up on. Ironically, when I had this
terrible fall, one of the reasons I was, you can say, happy
that I was going to Mercy Hospital was that it is my medical
home. It's where I had my gallbladder surgery. In other words,
all my records were there.
Ms. Ignagni, you'd be interested to know, because it was my
medical home as I arrived to the ER all my records were there,
and my primary care doctor's records were also available,
because, though not stationed at Mercy, he's affiliated with
Mercy. It made a tremendous difference in the immediate
response to a trauma situation, but then also on the ongoing
medical management and the postdischarge.
We really want to, no matter what goes forward, do that.
This is where we can work with the industry as well. You see, I
think that there's a lot of consensus, particularly around
administrative simplification, quality initiatives that we've
worked on. We're going to come back.
But for you, what are the top three things that we need to
get done in insurance reform?
Ms. Greenberger. We need to make sure that we deal with the
problems of preexisting conditions, the insurance market
reforms that deal with gender rating and other unfair bases of
rating.
Senator Mikulski. Gender rating, preexisting conditions.
Ms. Greenberger. We also want to make sure that the gender
rating applies outside the individual market, the protections
against it, so that it also deals with the group plans, both
employer-provided and association and other affinity group
provided plans as well. That's one constellation of issues.
Preexisting conditions is a related issue that needs to be
addressed, as well as exclusions of coverage, like maternity
coverage. That kind of reproductive health care that women need
is very essential.
Another thing is the affordability, so that we get rid of
lifetime caps, so that people like Ms. Buchanan can actually
afford insurance, because she could be the best--and I suspect
from what I've heard she is--the best investigator of what
plans are out there as possible, but if none of them are really
affordable and they have these other problems that's not--
that's what we hope health care reform will help her with.
There are a variety of those affordability protections as
well. And we want to make sure that there is the kind of
competition in the market so that these reforms translate into
actual quality, comprehensive and affordable health care for
women and their families.
Senator Mikulski. Very good. Thank you very much.
We haven't even talked a lot about prevention. We could
have this hearing now, we could come back this afternoon, we
could then take a break and find consensus. But then this is
going to be an ongoing debate.
Ms. Roth, what do you think--first of all, do you think we
need insurance reform? I know you talked extensively about your
concerns about the impact of both the HELP Committee and the
Finance Committee. But do you think we do need insurance
reform, and what do you think would be the three top elements?
Ms. Furchtgott-Roth. Well, I think that we definitely need
insurance reform. We can see that the auto insurance, the home
insurance, the life insurance markets, those are all working
very well, although if we're putting in a plug for equal gender
rating I have five boys and one girl and my three teenage boys
have to pay far higher auto insurance rates than my teenage
girl, and I think that that should be fixed, too, while we're
at it.
Senator Mikulski. We're for that.
Ms. Furchtgott-Roth. But there's tremendous problems in
just purchasing insurance. My husband is self-employed. I have
a job. I have to stick to a job where the job provides
insurance, so that my family has insurance. This just is not a
way to run a system. I should be able to go out and buy
insurance just like I can buy auto insurance.
What we need is a system where it's de-linked, insurance is
de-linked from the employer, insurance companies compete,
preferably over State lines, so that someone who lives in a
State such as Iowa can also get offers from companies in New
York or California, other kinds of companies. We need
competition, and we also need malpractice reform to deal with
these problems of high suits and high malpractice premiums.
What we need to do is try to make the health insurance
market into the same market for other insurance. It really got
messed up in the 1940s when there were wage caps, and so
instead of offering higher wages employers offered health
insurance.
They've continued to offer health insurance. We need to be
giving individuals that tax credit. Ideally, we wouldn't give
anyone a tax credit for health insurance, but we are stuck with
that politically because people are used to it. We need to de-
link it from the employer and give it to the individual
American so everyone can shop around for their policy.
Some people might want a bare-bones catastrophic policy
with a higher deductible. Others might want more of a managed
care policy, and people should have the choice of different
plans. And with competition, then we will find that if an
insurance company does what they did to Ms. Robertson that
would be publicized. They would hopefully lose market share, go
out of business. People wouldn't use those.
I mean, I heard an ad on the radio for Nationwide. It said:
``Well, have you been denied auto insurance coverage because of
an accident? Call us up; we will give you insurance.'' We need
people knocking down our doors to be giving us health
insurance. We don't have that right now.
Senator Mikulski. Thank you.
Ms. Ignagni, we recall when you did come in March, and I
think we've made a lot of progress and we really felt we were
pretty much on the same wavelength with administrative
simplification. I also thought we developed some excellent
recommendations on our quality initiatives, because quality
initiatives will help hospitals reduce preventable errors,
particularly the infection issue, using incentives in both our
Federal payment system as well as reimbursement in the private
market for the adoption of things like Pronovost's Checklist;
and also that significant issue of the management of chronic
illness.
We feel that there is much that we have found in terms of
common ground and welcomed your insights and recommendations in
looking at these models. Now, I want to be sure that I
understood your testimony. Are you saying that the industry, as
a whole, is now ready to end the practice of gender rating?
Ms. Ignagni. Yes.
Senator Mikulski. Is that each company or will that be a
general policy?
Ms. Ignagni. As a matter of where we stand on health
reform, Senator, our membership has endorsed that as part of
the guarantee issue, no preexisting conditions, equal premiums
across the two genders. We have strongly embraced that as part
of our basket of recommendations.
The only issue here, frankly, for us, but we're
considerably concerned about it, is the issue of, if we don't
have everybody in, potential hyperinflation. I know that many
leaders and you yourself are looking at that. The committee
here spent a great deal of time talking about getting everyone
in. We think that you're definitely in the right place. But we
are very concerned about the changes that happened in the
Finance Committee, because we want to get away from the
situation where it's a voluntary market, where the younger and
healthier don't have incentives to participate or would be
inclined to leave until they need health care, because then we
won't solve the problems that Ms. Robertson and Ms. Buchanan so
articulately emphasized.
From the beginning of the year we've been committed to a
massive overhaul of how the insurance market works, and we've
presented evidence of what happened at the State level when you
didn't have everyone in, and there were just--there was this
hyperinflation.
I think there's a real opportunity to understand that now.
We understand the sensitivity about penalties. We've offered
some solutions and alternatives to that. We very much want to
work with you. But if we don't end up with everyone in, we're
very concerned that at the end of the process when things
become available, people will feel very unsatisfied.
That is the issue we're pointing to, along with the issue
of, since cost containment across the system has been pretty
much taken off the table, we're worried about the underlying
costs. And we're worried that Congress has been forced into
some tax provisions that they wouldn't otherwise have had to be
forced into because of the lack of system-wide cost
containment.
Senator Mikulski. What you're saying is that the insurance
industry, with or without legislation, but preferably with--you
need a legislative framework, to end gender rating and the
barriers related to preexisting conditions.
Ms. Ignagni. Yes.
Senator Mikulski. Those were your three. What you're
saying, is that in order to do this, the market has to expand,
and that means that the insurance industry is calling for an
individual mandate?
Ms. Ignagni. Yes. We think----
Senator Mikulski. I just want to be sure----
Ms. Ignagni. Yes.
Senator Mikulski [continuing]. I understand, so I'm just
saying it out loud.
And by an individual mandate, what we mean is that we will
help to cover everybody, but everybody's got to participate?
Ms. Ignagni. Yes, Senator.
Senator Mikulski. Is that it?
Ms. Ignagni. Yes. And if there are concerns about the issue
of penalties and securing a mandate in that regard, we've
offered some alternatives to achieve universal participation.
We are strongly committed to the market reforms and they need
to happen.
Senator Mikulski. What would they be? Because, as you know,
this is a very controversial issue.
Ms. Ignagni. It is, and that's why I wanted to make the
point that I didn't want to come and suggest that we need
universal participation without also recognizing what you've
just observed. In our view, if Members of Congress were
concerned about moving down the penalty path, that they might
look at a basket of alternatives.
No. 1, in the Part D program and Part B program, as you
know, there are provisions where if you don't participate in
year 1, you pay more in subsequent years. That's one factor,
together we've been looking at, and I know there's been--in
Massachusetts, for example, one of the strategies that was
employed in the beginning of that legislation, which was
supported on a bipartisan basis, as you know, in Massachusetts,
was that if you didn't participate you lose your personal
exemption at the State level.
We have been thinking about ways to work in that concept so
that one could couple a personal exemption consideration with
perhaps some of the Part B, Part D types of penalties, or
looking at that way to encourage more people to participate.
We've been looking at auto-enrollment for people who would be
eligible for subsidies, and we'd be delighted to confer----
Senator Mikulski. Automatic enrollment, not the auto
insurance?
Ms. Ignagni. No, it's a little different than that, that's
right.
Senator Mikulski. The metaphors that we hear a lot of.
Ms. Ignagni. That's right.
But I think there are ways to solve those problems, and
we're committed to working with you to solve the problems. But
I think if you look at the experience in the States--and this
is what our recent report has pointed out--is that without
everyone in to secure the goal that everybody supports--and I
believe everyone supports it and that's the right thing to do--
we are going to have significant unintended consequences in
terms of costs, hyperinflation, if we don't get everyone in.
We want to recognize that now. We don't want to let
Americans down. It's very important. We promised that we are
committed to this. Our industry is four-square behind it. But
we have an obligation to explain how to get that, how to make
that happen.
Senator Mikulski. Well, again we could have extensive
conversations. I've got to get to a meeting with Senators Dodd
and Harkin. But I really appreciate every single person's
testimony. Each have added a very important dimension to the
conversation. As you can see, our desire was to have a
discussion, not a debate.
I think it's time--again, I'll come back to trying to find
that sensible center. We will be having ongoing conversations
with many of you at the table.
Ms. Ignagni, I'd like to talk with you about the issues
that Ms. Robertson raised. Knowing you and your longstanding
commitment on many issues related to women, I'm sure that
raised your eyebrows as well.
Ms. Ignagni. Yes, Senator. I'm happy to talk to you at your
convenience.
Senator Mikulski. If you have a way that we could deal with
the situation raised by Ms. Robertson across the board, maybe
we could work together on it before we develop the final
legislation--you know, developing legislation takes a long
time. But I think perhaps we can do some of these things.
I'm going to conclude this very important hearing and say
that we will keep the record open for any members wishing to
submit additional comments and questions. This committee,
stands adjourned subject to the call of the chair.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Senator Enzi
I believe we need to fundamentally reform the insurance
market place and offer new protections to ensure that
consumers--including people with pre-existing conditions--can
buy affordable, high quality health insurance. I strongly
support ending all discrimination based on pre-existing
conditions, whatever their cause. Everyone should be able to
get the health care coverage they need.
The bill I introduced in 2007, Ten Steps to Transform
Health Care in America, ended discrimination based on
preexisting conditions. Additionally, both the HELP Committee
bill and the Finance Committee bill end discrimination based on
preexisting conditions.
I believe there are many additional things we can do as
health care reform moves forward to improve the health of
women. Unfortunately, the bills the Senate is considering give
with one hand and take with the other when it comes to women's
health.
Multiple studies have shown, and CBO has confirmed that
health insurance premiums will rise for many Americans if
health care reform passes. Some studies have shown costs in the
individual market will increase by 50 percent or more. This
will have a negative impact on young, healthy women.
Additionally, many of the insurance market reforms,
including the very restrictive age rating rules capped at 2:1
in the HELP Committee bill and 4:1 in the Finance Committee
bill, will increase the cost of health insurance premiums for
younger, healthier women.
Many economists believe enacting a ``pay or play'' employer
mandate like the one included in the HELP Committee bill will
have a negative impact on low-income women and minorities by
lowering wages.
Additionally, the Finance Committee health care bill forces
14 million more people into the Medicaid and CHIP programs.
MedPAC reports show nearly 40 percent of doctors won't see
Medicaid patients because of the low reimbursement rates.
Forcing women into a program but not providing them actual
access to care is not progress.
In short, I don't think increasing health insurance
premiums, cutting wages, and forcing 14 million more Americans
into Medicaid is ``what women want.'' Madame Chairwoman, I
believe we can do better, for women and for all Americans.
[The Washington Post, May 5, 2008]
Malpractice Premiums, Rate of C-Sections Rise Together*
(By Kathleen Doheny)
Monday, May 5 (HealthDay News)--As medical malpractice premiums
increase, so do the rates of Caesarean sections, new research shows.
The study provides a small snapshot of the association, drawing on
data from the University of Connecticut Health Center in Farmington.
The findings, while not national in scope, could further fuel the
debate about whether higher malpractice rates boost the C-section
rates, or vice-versa.
---------------------------------------------------------------------------
* To learn more about C-sections, visit the National Institutes of
Health.
Sources: Jeffrey V. Spencer, M.D., maternal-fetal medicine fellow,
University of Connecticut Health Center, Farmington; Marsden Wagner,
M.D., perinatologist and epidemiologist, Tacoma Park, MD., and former
director, Women's and Children's Health, World Health Organization; May
5, 2008, presentations, American Society of Obstetricians and
Gynecologists annual meeting, New Orleans.
---------------------------------------------------------------------------
``When I compared the malpractice rates to C-section rates prior to
1999, both were declining at a similar rate,'' says study author Dr.
Jeffrey V. Spencer, a maternal-fetal medicine fellow at UConn. From
1999 to 2005, however, both were increasing.
The study was scheduled to be presented Monday at the American
Society of Obstetricians and Gynecologists annual meeting, in New
Orleans.
Spencer and his team reviewed the center's perinatal database from
1991 to 2005, noting how many vaginal deliveries and how many C-
sections took place. They got the average malpractice rates from the
primary carrier at their institution and adjusted them for inflation
over the years.
``I can't say one led to the other or vice-versa,'' Spencer said.
But he speculates the medical malpractice rates are driving up the C-
section rates. ``The theory is, doctors are practicing more defensive
medicine. Maybe doctors are fearful of litigation,'' he added, perhaps
likely to decide on a C-section at the first sign of any potential
problems.
In all, 23 percent (15,021) of the 64,767 deliveries studied were
C-sections. Spencer's team also looked at first and repeat C-sections
and compared those with the average malpractice premiums by year and
found a relationship between increased malpractice rates and both first
and repeat C-sections.
In a second study, Spencer and his colleagues looked at the impact
of increasing malpractice rates on what is known as ``operative vaginal
deliveries''--delivering a child by forceps or vacuum. They found that
16 percent (10,299) of the 64,767 deliveries were this type. From 1991
to 2005, average malpractice rates increased from $50,345 to $126,806.
The rates for malpractice rose, he said, even though both types of
vaginal deliveries declined. Forceps deliveries declined from 11
percent to less than 1 percent, and vacuum deliveries went from 17.2
percent to 6.2 percent.
Nationwide, C-section deliveries accounted for 30.2 percent of all
deliveries in 2005, according to the U.S. Centers for Disease Control
and Prevention, a record high for the Nation. In 1996, in comparison,
20.7 percent of deliveries were by C-section.
Another expert said the findings are nothing new.
``These two papers do nothing more than substantiate what we
already know,'' said Dr. Marsden Wagner, a perinatologist and former
director of Women's and Children's Health for the World Health
Organization.
One of the reasons for what Wagner refers to as the ``scandalous''
rate for C-section is that ``doctors are afraid of litigation.''
``Any physician who picks up a scalpel and does major abdominal
surgery, which is what a C-section is, because that doctor is afraid of
litigation, is not practicing medicine but is practicing fear and
greed,'' he said.
``The increasing C-section rate has not decreased the amount of
litigation,'' Wagner said. ``So their attempt to avoid litigation by
doing C-section is not working.''
Spencer agreed. ``The only thing to my knowledge that has changed
or lowered malpractice rates are States having legislation to place
caps on malpractice settlements.''
______
North Carolina Department of Insurance,
Raleigh, NC 27699-1201,
October 14, 2009.
Hon. Richard Burr,
U.S. Senate,
Russell Senate Office Building, Room 217,
Washington, DC 20510.
Dear Senator Burr: Since September, media nationwide has been
reporting on a 2008 National Women's Law Center report that includes
North Carolina on a list of eight States that allow domestic violence
to be used as a preexisting condition for health insurance policies.
These media reports have, understandably, caused much confusion and
concern from government leaders, women's advocacy groups, and
individual consumers across not only our State, but also the entire
country.
I want to state as clearly as possible, that the North Carolina
Department of Insurance and I strongly disagree with any assertions
that the status of being a victim of domestic violence is allowed to be
considered a preexisting condition in North Carolina.
For Group Coverage, North Carolina General Statute 58-68-35 section
A-1 specifically states that an insurance company may not discriminate
against participants or beneficiaries on the basis of evidence of
insurability, which would include conditions arising out of acts of
domestic violence. This provides protection from allowing domestic
violence as a preexisting condition for group plans.
For individual/nongroup plans--there is not a statute that
specifically lists domestic violence; however, there are several
broader requirements that we feel address this issue. North Carolina
Law defines a preexisting condition to mean ``those conditions for
which medical advice, diagnosis, care, or treatment was received or
recommended within the 1-year period immediately preceding the
effective date of the person's coverage.'' Domestic violence does not
meet the definition of a medical condition.
Further, in our regulatory oversight of health insurance policy
applications, we would not approve a company's policy application form
that attempted to use domestic violence in its underwriting decisions.
NCGS 58-63-15(7)b. gives the North Carolina Department of Insurance
the authority to review all policy application forms to make sure that
they are not unfairly discriminatory. In North Carolina, if a company
or policy wants to exclude something, they must declare it on the
application by asking the applicant directly about the exclusion.
Because exclusions are listed on application forms, and the Department
reviews and approves the forms, we would know if a company tried to
consider domestic violence as a preexisting condition.
We are unaware of any companies or forms that have asked to include
domestic violence as a preexisting condition. If they did, we would
deny it.
My department has been unable to find a single example of a company
asking an applicant if they have been a victim of domestic abuse or a
consumer complaining about being asked this for insurance purposes.
However, the issue is far too important to leave any possibility that
this could happen, so to create further protections, I have filed an
administrative rule for adoption in the North Carolina Administrative
Code--this is the most efficient way to address these concerns and add
to our insurance regulations. The new code forbidding domestic violence
from being considered as a preexisting condition should become
effective on March 1, 2010.
Should you have additional questions or concerns on this issue,
please feel free to contact me directly.
Warmest regards,
Wayne Goodwin,
Insurance Commissioner.
______
Consumers Union,
October 16, 2009.
Hon. Barbara Mikulski,
Senate HELP Committee,
Senate Dirksen 428,
Washington, DC 20510.
Dear Senator Mikulski: Thank you again for inviting Consumers Union
to testify at the October 15th hearing on issues in women's health
insurance.
During the hearing, Senator Merkley asked for more information
which I said I would provide for the record. If possible, I would like
to provide the attached for inclusion in the Record in response to his
question.
I hope the ``total cost'' information described in the attachment
can be included in the final health reform legislation. It would truly
help consumers make better choices while saving both consumers and the
Treasury significant amounts of money.
Thank you again.
Sincerely,
Jim Guest,
President and CEO.
______
Response to Question of Senator Merkley by Jim Guest
Question. Mr. Guest, you talked about the importance of having
apples-to-apples information for consumers to compare plans, including
examples of total costs a person would likely face. Can you explain a
little more about how that would work?
Answer. Thank you for the question. We believe that if you
correctly structure the information given consumers in the Exchange-
Connector system, you can:
provide enormous help to consumers in ensuring that
they pick the best policy for themselves, and
save consumers and taxpayers substantial amounts of
money by maximizing insurance coverage and minimizing consumer
out-of-pocket costs and taxpayer subsidy costs.
The first thing that consumers need is standard definition of
terms, so that they can comparison shop.
We have examples of consumers who thought they were buying hospital
insurance coverage, but the fine print showed that the coverage started
on the second day, after the huge costs of initial lab testing and use
of the surgery rooms. Standard definition of terms that all insurers
would be required to use would ensure that hospitalization meant
hospitalization in all policies. Consumers often think they have
pharmaceutical coverage and then find that chemotherapy and/or
antiemetics necessary for chemotherapy are not covered. A definition of
pharmaceutical coverage would prevent these kinds of ``got 'cha'
exceptions and allow consumers to shop on quality and price.
Insurance terms (e.g., co-insurance, tiers, etc.) should also be
standardized.
Second, most people are unaware of the huge expense of major
procedures, or even relatively common ones like childbirth. It would be
very helpful to require giving consumers ``scenarios'' of how the
insurance plan they are considering covers certain common conditions.
These would be defined and developed by the Gateway administrator in
consultation with medical experts and could include such examples as
childbirth, treatment of a certain level of prostate cancer, compound
leg fracture, etc. Not only would this show consumers why insurance is
important, but it would allow consumers to see that actuarially
equivalent policies can have wildly different levels of protection for
specific conditions. Our May issue of Consumer Reports (attached)*
showed two policies that appeared to be similar in premiums and
deductibles, yet in a case of successfully-treated breast cancer, one
policy left the consumer with $37,767 out-of-pocket, while another one
covered all but $7,668.
---------------------------------------------------------------------------
* The Report referred to may be found at www.consumerreports.org/
health/insurance/health-insurance/overview/health-insurance-ov.htm.
---------------------------------------------------------------------------
The most important thing you can do to help consumers pick the best
plan is to give them information, upon enrollment and at each open
enrollment period, of the plan's estimated total cost (premiums,
deductibles, co-pays), based on their past year's medical use or (on
first enrollment) their estimate of their health status (e.g., good,
fair, poor).
Consumers Union has just received a study by Destination Rx\1\ of
92,000 Medicare Part D enrollees that shows that if people selected
just on the basis of picking the lowest premium, their total spending
on drugs (premiums, deductibles, co-pays, donut) would be about $205
million annually. When other data is presented, such as the total cost
of the plan (based on their recent drug usage and past history), they
only spend about $172 million--a savings of $33 million among just
92,000 individuals. Of course, by selecting the best Part D plan for
themselves, taxpayers also benefit through reduced low-income
subsidies, minimized co-payments, and reduced catastrophic cost
subsidies.
---------------------------------------------------------------------------
\1\ We have used data from Destination Rx in a number of our
publications. They provided us with the data that showed that random
assignment of LIS beneficiaries in Part D to low-cost premium plans
often failed to ensure assignment to the best plan, from both the
beneficiary and the taxpayer point-of-view. This led to the
``intelligent assignment'' amendment of 2007 that CBO scored as saving
$ 1.2 billion over 10 years.
---------------------------------------------------------------------------
We believe that the same shopping ``principle'' applies to the non-
Rx health insurance market: if consumers using the proposed
``Exchanges'' saw the total probable cost of premiums, deductibles, and
co-pays based on their past year's medical use or self-described
medical condition (e. g., ``excellent, good, fair, or poor'' health
status as defined through regulations), they would tend to select the
lowest total cost plan--and thus minimize the deductible and co-pay
subsidies needed for those under 400 percent of FPL.
We urge you to amend the health reform bills to require that among
the information given to consumers in the insurance policy and/or in
the exchange, there be ``an estimate of the total annual cost for a
person enrolled in the policy, based on the individual's past medical
cost or based on self-assessed health status (data and estimates to be
developed by the Secretary through regulations and subject to all
privacy safeguards). This would be similar to the Medicare ``drug
compare'' Web site, where an individual can type in their medications
and see an estimated total annual cost. Very often, the lowest cost
plan is NOT the plan with the lowest premium.
Further immediate, scorable savings could be achieved in Medicare
Part D (and probably Part C), if you required that in each open
enrollment period, whenever possible beneficiaries were given an
estimate of their total cost for the coming plan year, based on past
Part D usage. They could then be shown the 5 or so lowest-cost plans
(counting premiums, deductibles, and co-pays) that would meet that past
usage. This could be achieved by amending 1860D-1(c)(3)(A)(ii). (This
would be somewhat similar to the requirement in MMA that a pharmacist
tell a beneficiary if their plan covers a lower cost generic.)
[Whereupon, at 12:30 p.m., the hearing was adjourned.]