The Center for Public Integrity

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.

If you wonder why the health insurance industry has to set up front groups and secretly funnel cash to industry-funded coalitions to influence public policy, take a look at the most recent results of the Kaiser Family Foundation’s monthly Health Tracking Poll.

In its November poll, KFF added a few new survey questions to find out exactly which parts of the Affordable Care Act/Obamacare are the most popular and which are the least popular. Insurers were no doubt annoyed to see that the provision of the law they want most — the requirement that all of us will have to buy coverage from them if we’re not eligible for a public program like Medicare — continues to be the single most hated part of the law. More than 60 percent of Americans have an unfavorable opinion of that mandate.

When it comes to what Americans like most about the law, the runaway winner is one of the provisions insurers most despise—the one that requires them to provide us with easy-to-understand benefit summaries. That element of the reform law was viewed favorably by a whopping 84 percent of the public.

Until now, insurers have been able to get away with providing skimpy and often incomprehensible information about their benefit plans, including what is covered and what is not and how much policyholders will have to pay out of their own pockets if they get sick or injured. The insurance firms have shown no willingness to communicate with their customers in a more forthright way, which is why an act of Congress was necessary to get them to do just that.

As I wrote a few weeks ago, the industry and its allies are lobbying the Obama administration to ignore that part of the law, arguing that to comply will cost millions of dollars that insurers would have to pass on to consumers. The companies insist that providing understandable information allowing us to compare plans serves no purpose that would justify the additional cost.

The Obama Administration will be making some important decisions over the coming weeks that will determine to a large extent whether consumers or health insurers will be the biggest beneficiaries of health care reform.

When Congress passed the Affordable Care Act last year, it included a controversial provision that insurers insisted on but which is undoubtedly the most unpopular part of the law: a requirement that all Americans not eligible for a public program like Medicare or Medicaid must buy coverage from a private insurance company.

To make that mandate fairer and more palatable, Congress also included provisions that eventually will make several of the insurance industry’s most egregious practices illegal, such as refusing to sell coverage to people just because they have a pre-existing condition. The law also prohibits insurers from selling “junk” insurance and from cancelling policyholders’ coverage at the time they need it most—when they get sick.

Just as important, the law requires insurers to spend at least 80 percent of our premium dollars on actual medical care, and it requires them to provide us with much more information—in language we can understand—to help us choose a policy that makes the most sense for us and our families when we’re shopping for coverage.

The Obama administration has the responsibility of writing rules to carry out all of the law’s provisions, and several of those rules are expected to be announced soon.

Many consumer advocates are concerned that the administration is listening more to insurers than to them. And possibly for good reason.

One of the reasons why Congress has been largely unable to make the American health care system more efficient and equitable is because of the stranglehold lobbyists for special interests have on the institution.

Whenever lawmakers consider any kind of meaningful reform, the proposed remedies inevitably create winners and losers. Physicians’ incomes most likely will be affected in some way, as will the profits of all the other major players: the hospitals, the drug companies, the medical device manufacturers, and the insurers, just to name a few. The list is long, and the platoons of highly paid and well-connected lobbyists who represent their interests comprise a large private army that conquered Capitol Hill years ago.

One has to wonder, then, how in the world Congress was able to include a provision in last year’s health care reform law to establish an independent board that would strip Congress of some of the authority it currently has — but rarely is able to exercise — over the Medicare program.

Everyone knows that without reform, Medicare is not sustainable. As the population ages and medical inflation continues, the amount of money the program will eventually have to pay out to cover beneficiaries’ health care needs will exceed revenues.

But because of the power and influence of the lobbyists and the organizations they represent, Congress has not been able to do much more than tinker around the edges. Recognizing that reality, a few lawmakers who were not so beholden to the special interests were able to insert language in the reform law to create a panel of 15 health care experts, to be appointed by the President, called the Independent Payment Advisory Board, or IPAB.