Health reform leaders urged to follow Crusader model

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ROCKFORD — However huge the health care system overhaul turns out to be, it’s almost certain that you will have to buy insurance if you don’t have it now.

That’s a worrisome proposal for Dennis Case, a Rockford small-business owner who’s lived without most insurance most of his working life. How, he wonders, will he be able to afford insurance when he can’t now?

“Tell me I have to buy insurance, and the only people who are helped are the insurance companies,” the 57-year-old said. “That’s not saying people are going to get more health care or get in to see a doctor.”

Some policymakers would point Case to the government-run plan, or public option, that would use income guidelines to collect premiums from individuals but pay lower reimbursement rates to doctors than private insurance.

The Senate Finance Committee shot down two recommendations last week for how to structure that option, although some version of government-subsidized insurance is included in the House and Senate bills.

It’s unclear whether a government option will be included in the final legislation, but congressional leaders aren’t backing down from an individual mandate to buy health insurance. So the public option has become a bargaining chip, giving way to partisan support for tighter restrictions on the insurance industry.

Policy experts say these are necessary steps in making coverage more affordable for individuals.

“Almost certainly that there will not be a true, full-blooded public option in the final legislation that passes,” said Tom Oliver, a professor of population health sciences at the University of Wisconsin-Madison. “But what we’ll end up with is a stronger system of insurance that’s more open and fair. Insurance will be made more affordable for everybody as a result of having a lot of people standing up for the public option.”

Finding common ground
Policymakers agree on certain insurance regulations, such as lifetime spending limits and eliminating the ability to deny coverage based on pre-existing conditions.

And the government subsidies being discussed — based on federal poverty guidelines — to require people to buy their own insurance range from limiting premium costs based on income, fixed-dollar subsidies, tax deductions and tax credits, according to the Washington-based Kaiser Family Foundation.

Oliver thinks the affordability issue boils down to keeping insurance rates predictable and stable, something the government, with its leveraging power, could do. Insurance exchanges and member-run insurance cooperatives are on the table as ways to create more competition with the private sector, but they still will require people to pay.

Donna Friedsam, director of health policy programs at the UW-Madison Population Health Institute, compared health insurance exchanges to a store selling policies, where people can browse for the best option.

The exchanges would spread the effect of expensive treatment for individuals and businesses having a hard time affording coverage now. In an exchange, the insurers have to play by the government’s rules and sell to anyone who comes to the “store.”

But Friedsam recognizes legitimate concerns about the public option.

One is talk about the public option using Medicare rates, which are lower than private insurance rates, to reimburse providers. Another is the insurance industry, which must compete with such low rates. A third is differences in estimates of how many people, given the opportunity, would migrate to federal coverage.

Friedsam said negotiations have addressed using higher reimbursement rates, for example, so she thinks we haven’t heard the last word on the public option.

“Theoretically, we could certainly go without a public option if we have very heavy regulation on the insurance industry, but that’s not the way we operate,” she said. “The amount of regulation to achieve the same goals would be in and of itself a political battle.”

Local programs a model
Case hopes reform leaders will recognize viable health programs like Crusader Community Health, where he goes for doctor visits. He recently became a board member for Crusader, which is federally mandated to have patients on its board of directors.

Regular visits to Crusader identified and treated his Type 2 diabetes and a heart blockage that led to surgery at SwedishAmerican Hospital. Case thinks the government should build on the community health center model.

“If I’m forced to buy insurance for myself and for my employees, I’d have to let people go to make up the difference, and that’s being counterproductive,” he said. “Even if there are exemptions for small businesses and certain people, who’s going to be forced to make up the difference? Will the American public be taxed even more?”

Crusader offers a sliding-fee payment scale, based on patient income, for uninsured clients. Chief Financial Officer Sam Miller said the number of uninsured patient visits was up 27 percent in May, a trend expected to continue as more people lose jobs and health insurance.

Crusader is seeing all payment areas increase, Miller said. As of May, 58 percent of Crusader’s patients were on Medicaid, 28 percent were uninsured, 7 percent were on Medicare and 7 percent had private insurance.

“Any direction (reform) goes, the community health center model is part of the solution and, quite honestly, should be,” Miller said.

Crusader officials are watching how reform proposals will address affordability.

Hospital charity care programs work on a similar scale, where patients provide income documentation to help them pay for care if they’re uninsured or if there’s a balance after a third party has paid.

David Stenerson, vice president and CFO at OSF Saint Anthony Medical Center, said charity care started growing toward the end of 2008 and hasn’t let up. He said the health systems are watching to see how reform could change the charity care models.

Reach staff writer Melissa Westphal at 815-987-1341 or mwestpha@rrstar.com.

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Special report: Health care reform