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ADVOCACY NEWS: Response to Affordable Care Coverage Recommendations

Friday, May 29, 2009

May 22, 2009

The Honorable Max Baucus                                 The Honorable Charles E. Grassley

Chairman                                                          Ranking Member

Committee on Finance                                        Committee on Finance

United States Senate                                          United States Senate

Washington, D.C. 20510                                      Washington, D.C. 20510

RE: Response to Affordable Care Coverage Recommendations

Dear Chairman Baucus and Ranking Member Grassley:

The Amputee Coalition of America (ACA) is the leading national organization serving the needs of people of all ages living with the loss or absence of limbs.  We have members, industry partners, peer visitors and support group leaders throughout the country.    

The ACA is pleased to submit written comments on  the Senate Finance Committee’s set of recommendations regarding policy options for health care coverage contained in the document Expanding Health Care Coverage: Proposals to Provide Affordable Coverage to All Americans.  In summary, the ACA is supportive of the recommendations regarding individual and small group market reform.  These improvements to the private health insurance market will have significant positive implications on the ability of all Americans to access affordable health insurance regardless of their health status.  We also strongly support the recommendations regarding Medicaid, including recommendations that serve to eliminate the two year waiting period for disability coverage and inclusion of disability status as a category for purposes of measuring health disparities.

The ACA is deeply concerned, however, with the limited scope of the benefit package that would be available under the Health Insurance Exchange.  Based on the document released by the Committee, there is a complete absence of any benefits related to rehabilitation therapies and related services (in both the inpatient and outpatient settings) as well as durable medical equipment, orthotics, prosthetics (DMEPOS) and other assistive devices. 

Arms and legs are not a luxury.  Prosthetic limbs are essential items that enable people with limb loss to function as working, tax paying citizens.  These benefits are not luxuries or convenience items.    This apparent lack of coverage would have devastating consequences for individuals in need of this care to facilitate their recovery and restore their ability to function and live as independently as possible.  These benefits are no less important than antibiotics to a person with an infection, open heart surgery to an individual with coronary artery disease, or setting a limb that has been broken.  Congress must explicitly require coverage of these two categories of benefits (i.e., rehabilitation therapies and DMEPOS) in all insurance plans offered under the Exchange and must do so in statute. 

Almost two million Americans are living with limb loss or limb deficiency as a result of disease, trauma or birth defect.  As the emerging public health crisis of diabetes continues to escalate, so will the number of amputations.  It is essential that the needs of people with limb loss are taken into consideration as health care proposals are developed in order to ensure that they are able to lead independent, productive lives.  

Set out below are our responses to specific recommendations presented in the Finance Committee document that are of particular significance to people with limb loss.

I.          Individual and small group market reform options.

The ACA supports the following reforms included in the proposal:

o        Imposing guaranteed issue and guaranteed renewal rules on coverage in the individual and small group markets.

o        Prohibiting pre-existing health condition exclusions in these same markets.

o        Restricting premium rating practices in these markets to prohibit the use of health status in determining premium rates.

o        Establishing a single “Health Insurance Exchange” for all insurers in the small and individual market; or establishing multiple competing exchanges in addition to the national exchange.

These insurance market reforms would constitute significant improvements to the insurance market for people with limb loss.  These reforms alone would have a major impact on the ability of individuals with health conditions to access affordable private insurance.  Of course, whether this coverage will ultimately meet the needs of people with disabilities is dependent on the benefits that are actually covered under these private insurance plans. 

The ACA believes that it is imperative that health care reform meaningfully address catastrophic medical events through restrictions on annual or lifetime limits so that individuals and families are not exposed to unlimited out-of-pocket expenses.   Out of pocket limits and/or cost sharing for vulnerable populations must be emphasized. 

II.       Minimum benefit package, subsidy and tax credit options.

For the individual and small group markets, the proposal suggests the establishment of a minimum benefit requirement that covers preventive and primary care, emergency services, hospitalization, physician’s services, outpatient services, day surgery and related anesthesia, diagnostic imaging and screenings, medical/surgical care, prescription drugs, radiation and chemotherapy, and mental health and substance abuse services. 

The proposal also suggests a requirement that each plan apply “parity” for cost-sharing treatment of conditions within each of the following categories: inpatient hospital, outpatient hospital, physician services and other items and services, including mental health services.

Seventeen states have passed parity legislation creating consistent standards of care for prosthetic devices.  Congress is currently considering HR 2575, the Prosthetic and Orthotic Parity Act.  It is clear that the public also expects parity in coverage for assistive devices like prosthetics and orthotics.

·         For children with spina bifida, access to a custom orthotic device impacts both their short and long term mobility, their muscle strength, and overall quality of life.  As they mature, the orthotic device allows them to maintain their maximum level of functionality. 

·         The purpose of a custom orthotic device for people with cerebral palsy is to protect, such as stabilizing a fracture during healing; to prevent deformity, such as stretching braces worn while the person sleeps, to help prevent muscle contractures; and to improve function.  This can help children with cerebral palsy achieve maximum potential in growth and development.  

·         Those with limb loss can and want to regain the quality of their lives.  Prosthetic devices and related services enable amputees to continue working and attain levels of function that were not possible in years past.

One of the most critical aspects of the health care reform debate for the disability community is the assurance of an appropriate set of benefits to meet the needs of people with limb loss and other disabilities.  The ACA is seriously concerned that the proposed benefit package fails to specifically include coverage of rehabilitation services (in the inpatient and outpatient settings) and durable medical equipment, prosthetics, orthotics (DMEPOS) and other assistive devices.  For people with limb loss and other disabilities, rehabilitation services and devices are a necessity to maintain and improve function.  Acute and post-acute rehabilitation services should be covered in multiple settings of care to match the level of intensity of rehabilitation needed by the patient, including inpatient hospital rehabilitation—where the focus is on intensive, short term rehabilitation in order to return the patient to their home and community as quickly as possible—throughout the continuum of care.

It is imperative that a basic benefit package recognize the value of improving functional status, not simply meeting the acute care needs of people with illnesses or injuries.  For instance, a basic benefit package must cover:

·         Intensive medical rehabilitation services provided in the inpatient setting;

·         Post-acute care in a variety of settings to ensure the most appropriate rehabilitation;

·         Outpatient therapies that will restore, improve, and maintain function, as well as such services to prevent the further deterioration of functional status; and

·         A full complement of durable medical equipment, orthotics, prosthetics, and medical supplies, without arbitrary and unreasonable dollar limits or exclusions.

Without appropriate prosthetic and orthotic care many people with complex, disabling conditions are at risk of developing dangerous and costly secondary complications.  Furthermore, the delay in appropriate care has a profound impact on the ability of individuals to maintain and enhance function, become and remain independent and to reach their full potential. The subsequent cost to the healthcare system far exceeds that of providing prosthetic care.

If people with limb loss do not have their needs met by private insurance they will ultimately, be forced to avail themselves to the public programs that do offer such coverage.  This result is little different from the current situation for these populations.  A reformed health care system must do better.  Prosthetic and orthotic devices should be seen as an essential part of any benefit package or standard. 

III.      Public health insurance options.

There are strong arguments in favor of a public plan, mainly to act as a competing plan to all private health plans in the Exchange, thereby putting pressure on private insurers to offer attractive benefit packages with reasonable premiums.  There are many ways to structure a public plan option that would not lead to a government “take-over” of health care in this country.  The ACA is open to further discussions on a variety of methods by which this could be accomplished. 

IV.     Role of Public Programs

The ACA believes that there are many positive features in this section of the policy options, including:

·         A strengthened benefit package for children so that all children in public coverage (Medicaid and CHIP) have access to the full range of treatment necessary to attain and maintain their optimal health and development;

·         Extension of new quality provisions that the Children’s Health Insurance Program Reauthorization Act (CHIPRA) applied to children in Medicaid and CHIP to all Medicaid beneficiaries, including people with disabilities;

·         Recognition of the need for increased provider payments to ensure access to services, although we suggest consideration of alternatives to an across-the-board increase that may be more effective in matching higher payments to health care services where access problems have been reported.

Most of our comments relate to the three approaches for Medicaid coverage.  Our preference would be for Option 1, which would use the current Medicaid structure to cover parents, pregnant women, and children with incomes up to 150 percent of the poverty line and adults without children with incomes up to 115 percent of the poverty line.  As explained in a recent report from the Kaiser Commission on Medicaid and the Uninsured building on Medicaid makes sense. Medicaid currently provides affordable and comprehensive coverage that is well-suited to low-income and high-need populations in an efficient and cost-effective manner.  In addition, Medicaid already has an administrative structure in every state that is ready to assume new groups of beneficiaries.[1]

ACA believes that these recommendations, taken together, would enhance existing public programs to cover more Americans.  The problem, however, is that a Health Insurance Exchange with federal subsidies available to low income persons will inevitably tempt states to no longer

cover optional populations (in which they are required to contribute to the cost of Medicaid).

Another issue is that the standards in Medicaid benefits vary from state to state in terms of what is covered.  This is especially true for prosthetic devices.  Congress needs to look at working with states to create more consistent standards for these important services.   

V. Regarding the Medicare Disability Waiting Period

The ACA applauds the Finance Committee for including options to reduce or phase-out the Two-Year Medicare Disability Waiting Period. This policy has not only been a significant barrier to health care for almost 2 million people with significant disabilities but ultimately increases costs to the Medicare program due to delayed medical treatment.  The ACA has been active on this issue as part of the Coalition to End the Two Year Waiting Period.

In order of preference we recommend:

• Approach 3, which would reduce the waiting period in six month increments, with complete elimination after one-and-a-half years;
• Approach 2, which would phase-out the waiting period by 2015;
• Approach 1, which would reduce the waiting period to 12 months.
• Approach 4, which would maintain the waiting period for people with access to private insurance that meets or exceeds an actuarial standard.  However, we are concerned that an actuarial standard does not guarantee that coverage will be affordable or that out-of-pocket costs will be limited.  Moreover, as underscored above, we are very concerned that the benefit package will be very limited and may fail to include access to critical services (i.e. rehabilitation, therapies, durable medical equipment, orthotics and prosthetics) that allow people with significant disabilities to function;

In addition the ACA supports the proposed temporary Medicare buy-in for individuals between the ages of 55 and 64. This population is vulnerable to disability and access to health insurance coverage may prevent the onset of chronic conditions and disabilities.

VI.  Health Disparities and Public Reporting

The ACA is particularly pleased with the proposal to add disability as a health disparity category alongside race, ethnicity, gender, and rural status.  We also strongly support requirements for CMS to determine where people with disabilities access primary care and the number of providers with accessible facilities and equipment to meet the needs of persons with disabilities. The addition of “disability” as a category for purposes of tracking health disparities is a significant advance for those with chronic illnesses and disabilities, as ongoing monitoring and reporting will raise the awareness level on the disability population’s unequal access to quality health care services.  

The ACA understands that health care reform presents an enormous challenge.  We feel that any healthcare reform proposal that truly gets at improving health systems and enhancing access must address the healthcare needs of people with limb loss.  We hope that our suggestions will help in this complicated process.  We applaud the efforts that have been made by Senate Finance to improve access for all Americans in need of healthcare. 

We urge you to continue to strive to ensure that people with limb loss are not left out of the discussion.  Coverage for all Americans must include adequate and appropriate coverage for people with disabilities. 

Sincerely,

Kendra Calhoun              Dr. Jeffrey Cain                          Morgan Sheets

CEO & President             Board of Directors                      National Advocacy Director

*This page is funded by the ACA and not supported with CDC grant funding. Views expressed in the contents are solely the responsibility of the authors and do not necessarily represent the official views of the ACA.