This article first appeared in the St. Louis Beacon, Dec. 22, 2009 - About two dozen faith and community leaders from Missouri Health Care for All gathered at the St. Louis office of Sen. Claire McCaskill on Tuesday morning to deliver a special holiday card of thanks for her support of what many feel is a landmark health-reform bill.
Their visit illustrates the see-saw public reaction that McCaskill and many other lawmakers have received during months of debate as groups ranging from faith-based organizations to St. Louis Tea Party protesters have worked to influence the outcome of the legislation.
On this chilly Tuesday morning, however, only the proponents of health reform showed up at McCaskill's office, though the bill itself continues to draw both criticism and praise. In Missouri, some doctor and hospital groups still oppose it as unfair and too costly to their members, while groups such as Missouri Health Care for All say the measure, however imperfect, marks an unprecedented step toward making health insurance affordable for most Missourians and most Americans.
The Senate bill is projected to cost $871 billion over a decade and provide health coverage for 31 million Americans. Though the bill is projected to cover about 94 percent of Americans, it also would leave millions without insurance -- a sore spot for many proponents. But they stress that the benefits of the Senate and House legislation outweigh the shortcomings.
Health reform would be landmark achievement
"Health reform is something that the American people have long needed," Philippe Villers, president of Health Care USA, said in a telephone interview. "While I deplore some of the compromises, this is an important step, which the American people deserve even with the compromises."
Among those at McCaskill's office were the Rev. Ronald Bobo, pastor of West Side Missionary Baptist Church on the north side; Ruth Ehresman, director of health and budgetary policy at the Missouri Budget Project; and Amy Smoucha, a health reform proponent and an organizer for Jobs With Justice.
Smoucha called the health legislation "a historic opportunity to fix a problem." The proposal would take a big slice out of Missouri's uninsured population of more than 750,000, she said. Under the Senate proposal, at least 450,000 uninsured Missourians would gain access to health care because the legislation would cover people with income of up to 133 percent of the poverty level. For a family of four, that's $29,327. The House measure is even more generous, offering coverage to those with incomes of up to 150 percent of the federal poverty level. Under that threshold, a family of four with an income of $33,075 could still qualify for Medicaid.
Smoucha said, "We can make history. The legislation means people will be able to go to the doctor when they are sick, and that health-insurance costs won't continue to rise four times faster than wages. Instead of going to health insurance, more of their wages will go into their pockets."
The change certainly would make a big difference in Missouri's Medicaid program. It currently freezes out most of the working poor by limiting participation to those earning no more than 20 percent of the federal poverty level.
Ehresman said the bill "means we're a step closer to everyone having access to affordable health care, regardless of how old they are, for whom they work and whether they are healthy or sick. Definitely, it will mean that the lowest income working families that are priced out of affordable insurance will have options that allow them to get the care they need when they need it. I am pleased that we've gotten this far. This is the most historic social legislation since Medicare was passed over 40 years ago. We have a long way to go, but we're on the right road."
Recalling his own bout with cancer and feeling "blessed" to have health insurance to cover the $30,000 bill for his care, Rev. Bobo said he thinks of the thousands of north St. Louis residents who can't pay for routine care, let alone cover the cost of a catastrophic illiness.
"The people I'm talking about are undereducated," he said. "They are unemployed, and they can't get affordable health care and other things that Jobs With Justice stands for. My own medical situation made me understand even more the importance of having health insurance. But it's also important because health care is a basic human right. That's why what Congress is doing is so important to everyone."
Still, not everybody will be covered, notes Brian Colby, director of communications and outreach for the Missouri Association for Social Welfare, and the devil remains in the details.
"We're generally positive about this legislation," Colby said, citing provisions such as those that prevent insurers from penalizing people for pre-existing conditions.
"We think it's a huge first step. It's not perfect. There are many things we'd hope may be in the bill that aren't."
Some people will be left out by default, he said. "There always will be some folks who won't, for whatever reason, sign up for the insurance, just as some folks drive without car insurance. It's a very difficult system to sell everyone."
A major shortcoming, he said, is that certain immigrants might be left out. Illegal aliens could be shut out altogether. The House version would allow them to buy health insurance, with no subsidies to cover the costs, through insurance exchanges set up by states. But the Senate measure would not allow illegal aliens to buy insurance through exchanges even if they wanted to cover the cost.
So "we're still going to need a safety net," Colby said. "We're still going to have some uncompensated care with some folks going to hospitals and not having insurance. Either they will have to pay cash or the hospitals or doctors won't get paid. This is not a perfect solution, but it certainly is better than what we have now."
And he doesn't underestimate the changes insurance companies might try to make, such as raising rates to cover their financial interest.
"That's a legitimate fear," he said. "Again, it's something we're going to have to keep our eyes on. The hope is that through the exchanges, people will be able to shop around for better deals. They will be able to see apple-to-apple comparisons of health-insurance plans. So there will be more competition in the marketplace."
He added, "The other thing is that the rules have not been written. A lot will come down to the marketplace rules. Certainly this is not a perfect system, but we think it improves the system that we have."
High costs, Reimbursement cuts mar bill
The Missouri State Medical Association is opposed to both the House and Senate versions. The group's director of government relations, Tom Holloway, said the price tag was too high. The association also disliked the now-discarded Medicare buy-in plan.
"Medicare already is nearly bankrupt as it is," he said. "It's foolhardy to put more people in a system that's collapsing."
But a bigger concern, Holloway said, is the Medicare reimbursement formula that would require physicians to absorb a 21.5 percent cut in Medicare payments in January.
"The formula is used to update physician fees. Every year, they promise to fix it, but they just put a patch on it, and every year the pay cut goes up."
The state medical association's stance is different than some American Medical Association's positions on health insurance. The AMA recently decided to go along with the 21.5 percent cut. Its president-elect, Dr. Cecil B. Wilson, said their concerns were offset partly by the decision not to cut payments to specialty physicians and bonuses to doctors working in underserved communities.
Holloway said of the Senate bill, "It has been improved, but I don't think it has gone far enough to change our position."
Likewise, the Missouri Hospital Association expressed mixed views. The group's pesident and CEO, Herb B. Kuhn, saids the amount of uncompensated care by Missouri hospitals (estimated at $813 million in 2007) is proof that health reform is needed.
But he said Congress is headed in the wrong direction if it intends to reform the system by cutting more than $150 billion in Medicare and Medicaid throughout the next decade.
"These cuts will reduce payments to Missouri hospitals by as much as $2.8 billion," Kuhn said in a statement. "Hospitals already lose money on every Medicare patient they treat due to chronic underfunding of the programs. In 2007, hospitals lost more than $604 million on the unpaid costs of treating Medicare patients alone."
On the other hand, he said hospitals are hoping that expanded Medicaid coverage will help balance Medicare and Medicaid payment losses to hospitals.
Dr. William Fogarty, of Webster Groves, isn't as alarmed as some colleagues. The retired internist has been involved in health policy work for the last 18 years and is interested in health care for the under served and health care reform. He said in an interview that the Senate's plan has the potential to cut costs, but he added that "lots of things sound good on paper but can be extremely difficult to carry out in practice."
One issue he's concerned about is the proposal to bundle payments instead of paying each specialist individually as a way of holding down costs.
"The payment would be a lump sum divided among a hospital's doctors," he explained. "That makes a lot of sense until you sit down to see how you're going to divide the pie."
Even so, he said the model can work, and he's pleased by the steps the Senate has taken.
"It's not perfect. It's a downpayment on what needs to be done, a first step, a huge step forward."