Health Care Reform: What Does It Mean and Why Should We Care?

Wherever you live in the U.S., chances are good that policymakers, advocates, and others in your state are currently, or soon will be, discussing health care reform. If you think this has nothing to do with you, think again.

The outcome of health care reform debates will affect everyone, for better or worse. You are a citizen, a health care consumer, and a taxpayer. You may also be an employee, or a business owner. You may be a parent of young children. You may have parents of your own, who are growing older. In all of these roles, you'll feel the impact of change—or lack of change—in your state's health care system. And for people with disabilities, who may have more and/or different health care needs, the stakes are particularly high.

So, if your state has started developing and debating ideas for expanding and/or improving health care services, consider getting involved or at least paying attention. Not sure how to begin? Start by learning some of these basic concepts, and deciding where you stand on them:

Uninsured
According to the Commonwealth Fund, 45 million adults in the United States do not have any health insurance coverage.

Underinsured
Another 16 million U.S. adults have health insurance coverage that does not cover all the health care services they need; they have to pay out-of-pocket expenses that go beyond their ability to pay.

Access
While the disability community uses the word “access” to mean barrier-free usability by people with disabilities, it means something different in the health care context. Access means a person's ability to get the health care he or she needs. Access means being able to get good quality health care, without financial, geographical, cultural, or language barriers. People with disabilities may need to remind health care reformers that access also means things like wheelchair-accessible clinics, adjustable-height exam tables, sign language interpreting in medical settings, and written materials available in non-print formats such as Braille or audio recording.

Access also means that people can get the type of health care appropriate to their needs at various times in their lives, including any or all of the following:

• Primary care - Basic health care services provided to someone who first seeks medical attention for a new illness. This is the most common type of health care, encompassing general medicine, prenatal care, and well baby care.

• Preventive care - Services designed to keep people healthy so that they are less likely to develop health problems. For example, preventive care may include nutritional counseling, exercise classes, stop-smoking programs, and health education.

• Catastrophic care - Treatment for severe or lengthy injury or illness, such as cancer, or serious accidents.

• Mental health care - Services to treat or support people who have psychiatric, emotional, or behavioral health conditions, such as depression, anxiety, and more serious disorders like schizophrenia.

• Chronic care - Health insurance that provides care and treatment for people with ongoing, continuing health problems, such as diabetes, asthma, or arthritis.

• Long-term care - Health services, personal care, social services, and other supports needed by people who have permanent or long-term functional impairments related to age, disability, or illness. Long-term care includes both home health services and nursing facility placement.

Rating
When insurance companies calculate the cost of premiums people must pay for their health insurance, they use different kinds of formulas. There are two major types of formulas:

• Individual rating - A formula in which an individual's premium amount is based on a person's current health status and/or history of filing claims. This rating method can make it harder for people with disabilities or illnesses to get health insurance.

• Community rating - A rating method in which all subscribers within a particular area pay the same premium amount, based on the average cost of health services for all subscribers. This approach “spreads the risk” across all members, so that no individuals are penalized for their current health status or their claims history.

Cost shifting
The practice used by hospitals and doctors of charging paying patients—primarily those with private insurance—more, in order to recover the cost of providing care to uninsured or underinsured patients or those covered by such public programs as Medicaid and Medicare.

Medicaid expansion
Medicaid, authorized by Title XIX of the Social Security Act, is a government-funded health insurance program, combining federal and state dollars, and administered by states. Medicaid provides medical coverage to certain categories of low-income people, varying by state but generally including people with disabilities who receive Supplemental Security Income (SSI), children and their parents who receive Temporary Aid to Needy Families (TANF), and indigent elderly people.

Some health care reformers propose expanding Medicaid to make it available to more people, based on their income as a percentage of the government's Federal Poverty Level (FPL). Currently, FPL for a single person is $10,210. So, for example, a proposal to expand Medicaid to single adults up to 200 percent of FPL would mean that an adult with an annual income of $20,420 or less would be eligible for Medicaid. Current FPL for a family of three is $17,170, so a proposal to expand Medicaid to children up to 400 percent of poverty level would qualify children whose families make up to $68,680 for Medicaid.

Most proposals would expand Medicaid eligibility to people between 100 and 400 percent of FPL. Disability advocates have mixed responses to Medicaid expansion proposals. Some feel strongly that more low-income uninsured people—who may include our family members, our attendants, and people with disabilities who make just a little too much money to qualify for Medicaid—deserve to have coverage. Other advocates worry that attempts to cover more people may eventually, during tougher economic times, lead to cutbacks in services that are critically important to people with disabilities.

Insurance subsidies
For individuals not eligible either for government health care or employer-sponsored insurance, purchasing an individual insurance plan may be another way to get coverage. Many people cannot afford to buy health insurance on the open market, at least not without some help. Some reform plans include state-funded subsidies to help some people pay all or part of their insurance premiums. Again, most of these reform plans target lower income people.

Individual mandates
Many reformers believe that if uninsured people got coverage, they would be more likely to get primary and preventive care. They would therefore stay healthier and be less likely to need high-cost health services. Some states actually require citizens to have at least a basic health insurance plan, and impose financial penalties on those who don't.

Among disability-rights advocates, some favor individual mandates, partly because they spread the risk across a larger population. Spreading the risk means that more people pay into an insurance fund, including people who do not end up making many claims, and therefore more money will be available to pay for services for those who need them. Other advocates oppose this idea, fearing that it will unduly burden poor people, without necessarily giving them good access to health care.

Employer mandates
Some reformers advocate putting responsibility on employers, at least larger companies, to provide insurance to their workers. Those businesses who do not give health benefits to their employees would have to pay a tax or fee. This is sometimes called “play or pay.” Some disability advocates are against employer mandates, worrying that they could become another excuse for discriminating against disabled job applicants, based on the assumption that people with disabilities will need more health services, thus driving up companies' insurance premiums.

Managed care
Managed care systems, also called health maintenance organizations or HMOs, are financing and delivery systems that coordinate services for members in an effort to reduce costs and improve quality. These systems maintain their own networks of physicians and other health care providers, and either require or encourage their consumers to use those network providers. While disability advocates generally like the idea of coordinating and integrating services, especially for people with more than one chronic health conditions, they are also wary of HMO practices such as drug formularies and capitation.

Capitation
“Capitated“ health plans impose a fixed amount that can be paid for a person's health care services within a certain period of time, or over a lifetime, regardless of how much health care that person receives during that time. Many disability advocates oppose this kind of payment system, because it may deprive people who need a lot of health care of necessary services.

Now that you have a basic understanding of health care reform concepts, find out what's going on in your state, and make your voice heard!