Kaiser Foundation Reports Aimed at Informing Debate on Health Care Reform

The Kaiser Foundation has released three new reports and a video that collectively examine the range of health care needs and costs that people face today and the scope of coverage that may be available to them under health reform. One of the reports, Individuals With Special Needs and Health Reform: Adequacy of Health Insurance Coverage, is particularly relevant to people with serious mental illnesses. Under legislation pending in Congress, people would be required to obtain health insurance coverage, mostly from private companies. However, private insurance is generally designed to cover acute care services, and plans vary enormously. Studies show that millions of nonelderly Americans with health insurance policies are underinsured—that is, their coverage leaves them to pay large out-of-pocket amounts for covered and noncovered services.

The 21-page report uses examples of three people with special needs—a seven-year-old born prematurely, a 50-year-old man with a spinal cord injury, and a 45-year-old woman with a developmental disability. It compares their estimated expenses with coverage provided by the Blue Cross Blue Shield Standard Option (BCBSSO) plan. This plan is the most popular that is offered through the Federal Employees Health Benefits Program and is often cited as an example of generous job-based coverage. It covers services that many private insurers do not, including mental health care, prescription drugs, rehabilitation, and other critical acute care needs.

However, despite BCBSSO's comprehensive list of covered services, out-of-pocket cost-sharing expenses were estimated to be $5,000 annually for the three cases profiled. In addition, BCBSSO places caps on coverage for certain kinds of care, in particular a 75-visit annual limit on rehabilitative care. Such a limit would add annual costs of $8,000 to nearly $12,000 for the two adults cases profiled. Finally, BBSCO falls short in providing necessary long-term services and supports for individuals with disabilities, such as personal care and case management. Thus the three patients would each need to spend out of pocket an additional $16,000 to $17,000 annually for their uncovered long-term care.

The median U.S. household income is about $50,000. Total estimated out-of-pocket annual costs in the three cases range from a low of $21,360 to a high of $32,600 for the adult with a developmental disability. Thus it is clear that how health care reform ultimately defines the content of what insurance must cover will affect everyone, but it will matter most to people with chronic illnesses who have long-term service needs.

The second report, Children and Health Care Reform: Assuring Coverage That Meets Their Health Care Needs, takes a similar approach to the coverage of children. Under reform, many children will be covered through private plans, and some who are currently covered through public programs may be shifted to private plans. A key question is what coverage standards will be applied to these private plans under reform. The report uses the BCBSSO to estimate out-of-pocket costs for an otherwise healthy seven-year-old boy with asthma and allergies and a 13-year-old girl with cerebral palsy who requires a range of services and supports.

The Kaiser analysis found that a family with a relatively healthy child may still face significant out-of-pocket costs under the BCBSSO plan—$2,020 for the boy with asthma because of copayments, deductible and coinsurance charges, and the cost of noncovered services, such as over-the-counter medications and much of his dental care. For the girl's family, cost-sharing amounts would likely reach the plan's $5,000 annual limit on out-of-pocket costs for covered services (which could increase to $7,000 if any care is received from nonpreferred providers). However, the girl's physical and occupational therapy visits would exceed the yearly limit, and some of the equipment she relies on would not be covered. The family would have to pay these costs out of pocket—about $4,300—bringing annual out-of-pocket costs for the girl's family to more than $9,000.

The third report, Oral Histories: Report From a Dental Fair for Uninsured Adults, and a companion video cover interviews with attendees and providers at a weekend dental fair held in Virginia in April 2009, where more than 800 uninsured adults lined up outside a local high school—some sleeping in lawn chairs overnight—for services provided by about 150 volunteer dental professionals. A total of 776 individuals received treatment worth about $.5 million; 1,263 teeth were extracted (30 patients lost from a third to all of their teeth), and 789 fillings, 254 cleanings and fluoride treatments, 643 x-rays, and 25 root canals were provided. The report's authors note that in 2006, more than 100 million Americans were uninsured for oral health care for the full year, nearly three times the number who lacked health insurance. The nine-page report concludes with a call for coverage of preventive and primary oral health in any reform package.

Two other recent Kaiser reports examine the impacts of Massachusetts reforms. Legislation enacted in April 2006 greatly expanded public programs such as Medicaid, required almost all state residents to have health insurance, and mandated creation of state-subsidized plans to cover low-income adults without access to other insurance. In the 22-page Consumers' Experience in Massachusetts: Lessons for National Health Reform, researchers report on in-depth interviews they conducted with 15 Massachusetts consumers to better understand the impact of reform, especially on consumers' ability to access and afford needed care. Although reforms have significantly reduced uninsurance and underinsurance rates, some groups remain vulnerable. One is low-income workers with employer-sponsored health coverage. They are not eligible for subsidies to help pay for their insurance, and they have fewer protections in regard to the quality of their insurance than low-income adults with coverage under the state-subsidized plans. People with chronic conditions are another vulnerable group because of cost barriers. Although nominal copayments may be affordable for people who need care only occasionally, lower-income people who need ongoing care may quickly find the out-of-pocket costs unaffordable.

The second report, In Pursuit of Affordable Health Care: On the Ground Lessons From Families in Massachusetts, is based on focus groups conducted in 2009 and highlights residents' experiences obtaining coverage, accessing services, and managing out-of-pocket costs. Investigators found great improvements in access and affordability, but a particularly vulnerable group again stood out: people with serious or chronic conditions who have difficulty shouldering heavy out-of-pocket costs, such as copayments, that can add up to thousands of dollars annually. This report and the others are available on the Kaiser Foundation Web site at healthreform.kff.org .