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The New Health Dialogue

A Blog from New America's Health Policy Program

HEALTH REFORM: Sebelius Brings Us the "The Letter I"

Published:  April 23, 2010
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HHS Secretary Kathleen Sebelius jokes that she’s tired of the letter “H.” H1N1. Haiti. Health Reform. Good thing that the next letter is “I.” As in “implementation.”

Speaking to the Association of Health Care Journalists conference in Chicago, Sebelius outlined some of the first steps HHS, along with Treasury and the Department of Labor, are taking to get health reform up and running. The initial focus includes new regulations for insurers (coverage of sick kids, end of rescissions etc.) and starting the state-based high risk pools. HHS is also reaching out to educate the still-confused public about how health reform can help American families.

She also spoke (more below) with surprising frankness and wistfulness about a controversial measure that didn’t get in the law -- compensating doctors for taking more time to talk about end of life wishes with elderly patients. The provision that was lethally characterized as “death panels.”

First, as they might say on Sesame Street, Sebelius brings you the letter “I.”One of the first pieces of heatlh reform -- allowing young adults to stay on their parents' plans until age 26 -- is ahead of schedule. Several big insurers are expanding that coverage well ahead of the Sept 23, 2010 deadline. That means that college students graduating this spring won’t have a coverage gap. And young people starting out in entry levels jobs with no coverage (or those who don’t have jobs) can also get  insurance.

Sebelius said she and her husband could identify. Her own sons,  now 25 and 28, found work after college, but neither had insurance. Sebelius and her husband were able to shop for affordable coverage, but they saw other families who weren’t so lucky.

“We thought it was a good way to reach out to plans and say take a look at this, have your actuaries look, can you step up.” Several agreed, voluntarily, and Sebelius predicted more will follow. “It’s a strategy that makes sense,” she said.

But not everything between HHS and insurers is so easy, as the tussle over covering children with pre-existing conditions illustrates. Sebelius called that an “unpleasant surprise.” Insurers said the law was poorly drafted, that they didn’t really have to offer the children anything. Not true, said Sebelius. And if you have any doubts about the clarity of the law, she told them, just wait until you see the regulations. “Within 24 hours, the suggestion of a loophole was withdrawn.”

She didn’t think that would be the last tussle. In fact, she predicted “on-going hand to hand combat.”

And that’s just with the insurance industry. It doesn’t include the Republican governors.

Sebelius said health reform is a “state friendly” piece of legislation, in the sense that “it starts with the assumption that states are the regulators.” But states have to comply with the law. If they don’t, the federal government will come in. A state can try to opt out. But she noted it can’t opt its citizens out of rights and protections granted to them under federal law.

If a state doesn’t set up a high risk pool, HHS will step in with a national option. That isn’t necessarily going to happen. HHS has been talking to governors, state policy experts and Medicaid directors. Some decisions are still pending -- whether to have a list of “pre-existing conditions” that will qualify someone to get in the pool, or whether to just have people prove they were denied affordable coverage and have gone without for at least six months. (Most states that currently have pools do the latter.) Money will be divided among states under a formula similar to the one used for State Children’s Health Insurance Program allocations. (Sebelius said that information has been shared with the governors.) People in the pool will still have to pay, and it won’t be inexpensive. The pools are meant to be a stopgap or “bridge” to help people who need it most until reform comes onstream in 2014, and the premiums they will have to pay will not be inexpensive. Pools are neither a perfect nor a permanent solution.

Sebelius was asked what she regretted about the legislation, about what had been left out, such as that end of life provision. The Secretary responded by talking about her own mother’s death. She was in three different hospitals in the last 10 weeks of life. Sebelius’s father and her siblings tried desparately to get any one of the doctors, the “dozens of specialists running in and out” to sit down and talk with them. To explain what was happening. What was likely to happen. So families can make choices and prepare in ways that are right for them. “I know how helpful it would have been to have had that conversation two months earlier,” she said.

Encouraging doctors and patients to have those “incredibly personal, incredibly difficult end of life” conversations “would have been wonderful public policy,” she said. A lot of people she has talked to around the country agreed. Instead it was mischaracterized, “revved up into a lather”and disappeared as a piece of public policy.

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