NN&I - May 2010
Health Care Beat ple to not get insurance until they need it (a.k.a., the "fre-erider" problem). The only way to have guaranteed issue with affordable and predictable rates is to require everyone to purchase health insurance. As reported by a recent AP story, the policy of an indi-vidual mandate is not new, and has been supported by both ends of the political spectrum.4 Additionally, the dual inclu -sion of guaranteed issue and an individual mandate was included in the health reforms implemented in the state of Massachusetts in 2007 and have showed promising results to date.5 But the requirement to have health insurance is new and seen by some as an expansion of Federal powers and as such, 15 states have sued in federal court to chal-lenge the constitutionality of this requirement.6 Another major link in the chain that is strengthened is the Medicaid program. One of the biggest myths about Medicaid is that it is a comprehensive program for the poor and disabled. Truth is, Medicaid eligibility and coverage is based on a complex set of minimum Federal requirements and optional state coverage that lets a significant number of people to fall through the cracks. For example, except in a small number of states, Medicaid does not cover childless adults younger than 65. The new health care law expands the Federal government's minimum eligibility threshold for states to all individuals under age 65 with incomes up to 133% of the federal poverty level ($14,404 for an individual The expansion of Medicaid is the easiest way to extend coverage to the largest number of people at the lowest cost. But it also invites the criticism that it puts more people into a well-meaning but flawed system. Sweeping Medicaid reform should positively impact CKDBy Brady AugustineIn March, the Congress passed and President Obama signed the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148) and a related reconciliation package (P.L. 111-152), which make the most sweeping reform to health care in the United States since the passage of Medicare and Medicaid in 1965. While the American public is still divided when it comes to the new legislation (46% favor, 42% oppose, and 12% unsure according to the March 2010 Kaiser Tracking Poll1), it will make significant improvements for those who have or may develop kidney disease. All persons either at risk or being affected by chronic kidney disease will have guaranteed access to coverage at affordable rates, either through their employer, a state-based insurance exchange, or Medicaid. This will go a long way to potentially averting CKD altogether by proactively address-ing risk factors, identifying and treating CKD in a timely manner to slow its progression, and managing the transition to transplant or other renal replacement therapies. Making preventive care affordable The bill's comprehensive reforms center on expanding access to affordable coverage. In order to meet this objec-tive, it had to strengthen every link in the chain. Otherwise, it would have come up short like previous state and federal initiatives to guarantee access to coverage (e.g. state-based risk pools).2 The anchor of this chain is the dual inclusion in 2014 of guaranteed issue and an individual mandate. Until guar -anteed issue is implemented in 2014, the government will establish a temporary, national high-risk pool to provide health coverage to individuals with pre-existing condi-tions.3 Today, policies in the small and individual group market are medically underwritten, which means health insurers use medical and/or health status information in the evaluation of an applicant for coverage and the deter -mination of what premium rate to set for the policy. This often means that persons at risk for CKD and those with CKD often have a difficult time getting health coverage. Guaranteed issue basically does away with medical under -writing but its drawback is that it incentivizes healthy peo- Mr. Augustine is president and CEO of Aggressive Analytics, Inc. (www.aggressiveanalytics.com) based in Tallahassee, Fla., and a board member for the American Association of Kidney Patients. He served in numerous roles, including Senior Advisor to the Administrator, at the Centers for Medicare & Medicaid Services from 2002 to 2007 and Chief of Health Systems Development at Florida Medicaid from 2007 to 2008. He also authors a health policy blog on Medicaid at www.medicaidfirstaid.com. Health Care Beat www.nephronline.com18 Nephrology News & Issues May 2010 HCB_NNI0510_2.indd 18 4/19/10 9:03:15 AM
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