The Center for Public Integrity

All the attention paid to the debacle about coverage for contraceptives over the past several days obscured a broader, undisputed win for all consumers, including those who are pregnant or about to be pregnant.

While the media was obsessing about the contraceptives controversy, the Department of Health and Human Services unveiled a final rule that even the Catholic bishops should support. Starting this fall, insurers and employers that offer health care benefits must provide us with more clearly written information about what their benefit plans cover and how much of our own money we’ll have to pay if we get sick, injured or, yes, pregnant.

This is no small matter. Rumors had been circulating in Washington over the past several months that the administration would cave to the demands of the insurance industry’s trade organization that this requirement be gutted to the point of being meaningless for most Americans. The rule requiring that this information be written in plain English was part of the health care reform law.    

The powerful insurers’ group, America’s Health Insurance Plans (AHIP), reportedly was hard at work early last week trying to persuade its friends in Congress, including some Democrats, to flood the White House with calls urging that the new requirement be postponed indefinitely and apply only to benefit plans sold outside of the workplace. That would mean that the requirement, if ever implemented, would be of value to only a small percentage of Americans.

MONTPELIER, Vermont — You can’t see them. They’re hidden from view and probably always will be. But the health insurance industry’s big guns are in place and pointed directly at the citizens of Vermont.

Health insurers were not able to stop the state’s drive last year toward a single-payer health care system, which insurers have spent millions to scare Americans into believing would be the worst thing ever. Despite the ceaseless spin, Vermont lawmakers last May demonstrated they could not be bought nor intimidated when they became the first in the nation to pass a bill that will probably establish a single-payer beachhead in the U.S.

When he signed Act 48 into law on May 27, surrounded by dozens of state residents who worked for many years to achieve universal coverage, Governor Peter Shumlin expressed great pride in what had been accomplished.

“We gather here today to launch the first single payer system in America, to do in Vermont what has taken too long—to have a health care (system) that is the best in the world, that treats health care as a right and not a privilege, where health care follows the individual, not the employer,” Shumlin said.

The problem for Shumlin and his allies is this: it will take five years before Vermont can fully implement its new system, partly because the federal health care reform law prohibits states from undertaking more far-reaching reforms until 2017 unless granted waivers from the feds to do so. And though Vermont’s Congressional delegation is on board to pursue a waiver that would let the state set up a single payer system two years from now, the insurance industry’s friends in Washington are not keen to let that happen. That’s because they want to use those five years to persuade Vermonters that they really don’t want to go the single payer route after all.

Let’s say you have a Ford and decide to replace everything under the hood with Hyundai parts, including the engine and transmission. Could you still honestly market your car as a Ford?

That question gets at the heart of the controversy over who is being more forthright about GOP Rep. Paul Ryan’s plan to “save” Medicare, Republicans or Democrats.

If you overhaul the Medicare system like you did your Ford and tell the public it’s still Medicare, are you doing so honestly?

As I noted last week, PolitiFact, the St. Petersburg Time’s fact checker, decided that the Democrats’ claim that Ryan’s plan would mean the end of Medicare was so blatantly untrue it merited designation as the 2011 “Lie of the Year.” Republicans, whose erroneous claims about health care reform garnered “Lie of the Year” prizes in 2009 and 2010, cheered. Democrats, as you might imagine, jeered — as did some journalists and pundits.

PolitiFact’s Washington-based editor defended the choice by contending that Ryan’s proposal to restructure Medicare by providing beneficiaries subsidies to buy private insurance would not “end” the program. It would still be Medicare, he reasoned.

What he’s missing is that Ryan’s proposal would change the program so fundamentally as to represent the equivalent of replacing the engine and transmission.

I'm sitting by the hospital bed of a grateful Medicare beneficiary — my mother. She seems to be making progress in her battle against pneumonia, and she doesn't have the worry that many other patients here have about how they are going to pay their medical bills. Because private insurance companies and employers have shifted so many Americans into high-deductible plans, many of the younger patients here will soon find out that they are terribly underinsured and thus will be on the hook for thousands of dollars not covered by their policies. 

Earlier today I went to the gift shop to buy Mom a brush. Amid the Christmas candy, cards and cheap do-dads near the cash register was a basketful of something that brought back a painful holiday memory: little lacquered lumps of coal.

Several years ago, a friend who had been in the habit of giving me a biography of some long-dead politician or literary figure surprised me by giving me instead a Christmas stocking with nothing but a lump of coal in it. In her opinion, I had been such a jerk during the year I didn't deserve anything else. 

That lump of coal was probably the best present I've ever received. I was so wounded I resolved to be a better, more thoughtful person. I’m still working on that.

So knowing from personal experience how beneficial lumps of coal can be at the holidays, I have decided to give out a few lumps of my own to folks whose recent actions make them deserving recipients.

It was four years ago today that I received a phone call from a Los Angeles TV reporter that would change my life, although I certainly didn’t realize it at the time.

The reporter said she had been told that CIGNA, the big health insurer I worked for back then, was refusing to pay for a liver transplant for a 17-year-old girl, even though her doctors at UCLA believed it would save her life and her family’s policy covered transplants.

I didn’t pay much attention to the call at first because, as chief spokesman for the company, I had received many calls over the years from reporters seeking comment about benefit denials. We took them seriously, but usually didn’t have to do more than tell the inquiring reporters we couldn’t comment substantively because of patient confidentiality restrictions. If pressed, we’d email a statement to the reporter briefly noting that we covered procedures deemed medically necessary and that patients and their doctors could appeal a denial if they disagreed with a coverage decision.

More often than not, the reporter would either drop it or do a piece that was quickly forgotten and would largely go unnoticed outside of the local media market. I assumed the call from LA would be no different.

I couldn’t have been more wrong.

Nataline Sarkisyan had been diagnosed with leukemia just weeks before her 14^th birthday in 2004. Initial treatments were successful and the cancer went into remission. It came back two years later, however, and this time was more difficult to treat. She eventually had to have a bone marrow transplant, which CIGNA covered, but there were complications that damaged her liver. Her doctors felt, however, that she had better than a 60 percent chance of surviving five years or longer if she had a transplant.

The money that patients’ rights advocates have to spend trying to convince the Obama administration that Americans should have decent health care benefits pales in comparison to the boatloads of cash insurers and their corporate allies have on hand to do largely the opposite. But at least the advocates are now in the game.

Last week a broad coalition of patient-focused groups launched its “I Am Essential” campaign in an effort to make sure that when all of us have to buy health insurance in 2014, we will be getting good value.

When Congress passed the Affordable Care Act last year, it included a provision requiring that all health insurance plans sold a little more than two years from now must contain “essential health benefits.” It established 10 categories of required coverage: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management and pediatric services, including oral and vision care.

The Department of Health and Human Services has the responsibility of determining, with input from the respected nonprofit Institute of Medicine, just how comprehensive the coverage will have to be in each of those categories.

Insurers and employers who offer coverage to workers have been lobbying both the IOM and HHS to make the coverage requirements as narrow as possible. They want to continue marketing plans with skimpy benefits because they are less costly to employers and potentially more profitable to insurers. The problem with that approach, of course, is that millions of Americans will be forced to the join the ranks of the underinsured—already estimated at 30 million—if coverage they must buy is inadequate to meet their needs.