Better coverage, more doctors, more state jobs and more people insured are coming to central Illinois
Ed and Diane Osman have health insurance. The Springfield couple buys health insurance separately from two different insurance companies, together paying more than $13,000 each year for what they hoped was protection from huge medical bills if they needed health care.
“I’ve always had health insurance,” Ed Osman says. “It’s a necessity. I’ve had health insurance ever since I was married 38 years ago.”
But when both Ed and his wife had to have surgery last year – he for chronic foot pain and she for a hernia – Ed Osman says he wasn’t surprised that both insurance companies denied their claims.
“They just said it wasn’t covered,” Osman says, adding that his insurance agent went to bat for him and got his insurance company, Assurant Health, to pay at least some of the nearly $11,000 in medical bills from his surgery. Five months after his operation, however, Osman says he is still fighting with Assurant over who will pay, and he has paid about $6,000 out of his own pocket in the meantime.
“I got a statement Saturday saying they finally paid a radiologist just $50 from several months ago,” he says with obvious disgust. “If you’re late by a day paying your insurance, you could lose your coverage, but they can be late by six months and screw up your credit, and there’s not a damn thing you can do about it. It’s very much a double standard.” Diane Osman’s insurance company, Humana Inc., still refuses to pay for her operation.
It’s a familiar tale for many Americans needing health care: health insurance can turn out to be no assurance at all.
Stories like the Osmans’ are the reason Congress recently passed a sweeping health care reform law aimed largely at health insurers. The law includes measures that prohibit insurers from denying coverage based on pre-existing conditions, canceling policies when customers get sick, capping benefits paid over a customer’s lifetime or excluding from coverage certain long-term illnesses like cancer. The law also requires insurance companies to report data about health care expenditures to regulators, prohibits premium cost differences based on anything but age, geographic location or tobacco use, and it ends an exemption that allowed insurance companies to carve up markets and fix prices. It even requires insurance to cover preventative services like cholesterol and cancer screenings. In addition to insurance reforms, the law includes tax credits, tax hikes, Medicaid expansion, community health care funding and plenty more.
The Patient Protection and Affordable Care Act was signed into law March 23, after months of partisan bickering, failed compromises and mass confusion among Americans struggling to comprehend just what the novel-length 900page law does. In Illinois, it will likely have far reaching effects for individuals, insurers, businesses and health care providers.
What’s in it for us?
Health care reform has taken on three main components: insurance reform, coverage expansion and cost containment. In Illinois, the law will beef up state health insurance regulations, force insurers to cover certain previously-uninsured groups, expand Medicaid to cover more low-income populations and help build health care infrastructure to lower costs.
Illinois Department of Insurance director Michael McRaith says the new law is a “significant landmark improvement for Illinois families and businesses who purchase health insurance.”
Current Illinois law does not restrict health insurance rate increases, McRaith points out, adding that his department recently released a report showing rate increases in Illinois of up to 60 percent during 2009. While most increases were less dramatic – in the neighborhood of five to 15 percent – the state had no authority to regulate even the largest ones. The new law supersedes lax state laws on the subject, effectively giving Illinois the authority to control rate increases and enforce rules on how insurance companies spend money derived from premiums, among other powers.
McRaith says Illinois passed a law last year to provide independent, external review of denied insurance claims through state panels, and the new national law extends that protection to consumers with self-insured health plans – those whose employers act as their insurers.
“The effect is that doctors will now be making health decisions rather than insurance companies,” he says.
Dr. Jerry Kruse, chairman of Family and Community Medicine at SIU School of Medicine in Springfield, says the law will particularly benefit Springfield by encouraging primary care providers to expand services and hire more staff, which in turn increases access to care for under-served populations.
Kruse says certain “practice reforms” – such as Medicaid reimbursement increases and medical school loan help for primary care doctors – will bring more medical students and practicing doctors to primary care, the non-specialized form of medicine that has long seen a decline in practitioners. Only about two percent of medical students go into primary care. Kruse is particularly encouraged by increased Medicaid reimbursements that will prompt more hospitals to accept low-income patients, as well as other measures he says will build infrastructure and lower costs.
“If you’ve got this primary care infrastructure there, what you’ll see in hospitals is fewer unnecessary emergency room visits, fewer readmissions for chronic problems and hospitals focusing on patients who really need to be
continued on page 16
