No Man is an Island

Today’s Sacramento Bee story highlights an option that the administration is looking at to try and trim health care costs. The method essentially involves getting rid of some of the state’s 23 health plan benefits that are mandated by law. These hard fought patient protections range from cancer screening, to diabetes maintenance and treatment of mental illnesses.

One of the advocates of this idea is Michael Shaw, assistant director for the National Federation of Independent Business:

Shaw, whose organization represents 35,000 employers in the state, said that because group insurance plans are required to provide more benefits than individual plans, many small business have been priced out of the market.

“So we want to create a set of rules for all plans that treat individuals equally but do not cost people the ability to afford health care,” he said.

Shaw said single men, for example, should not be forced to pay for maternity care “simply because the state determined that it should be part of health coverage.”

First of all, Shaw needs to do his homework. California does not mandate maternity coverage and many small group plans don’t offer it – or if they do, it’s only after thousands in deductibles have been met.

Secondly, helping to shoulder the cost for maternity coverage is really the least young, single, virile men could do.

The substance of Shaw’s argument troubles me, though. He is essentially arguing that there is not public good in pooling together to collectively shoulder costs.

If you look at the state’s list of mandated benefits — with the exception of some of the family-planning benefits — none of the conditions are within a person’s control. You have it — or you don’t.

Shaw is saying that if you are unlucky enough to have — say — Alzheimer’s disease, osteoporosis or a mental illness, you’re on you’re own, because the healthy crowd doesn’t believe it should have to take care of you.

But what happens when someone who is healthy suddenly becomes unhealthy — and gets — say, prostate cancer. Then what happens?

Under Shaw’s idea, you pay for it yourself, or you don’t and face the consequences.

The lesson under this model: Pray that you never get sick.

Here is a listing of California’s 23 mandated benefits. All may be found in the state’s Insurance Code. (A similar list exists in the Health and Safety Code for HMOs regulated by the Department of Managed Health Care.)

  1. 10119(b): Mandated benefit granting immediate accident and sickness coverage to each newborn infant and adoptive child.
  2. 10119.5: Mandated benefit for involuntary complications of pregnancy, at regular policy benefits. Limited to those policies which provide maternity benefits.
  3. 10119.7: Mandated benefit for diethylstilbestrol (DES) conditions or exposure
  4. 10119.9: Mandated benefit for general anesthesia for dental procedures performed in a hospital or surgery center on patients under age seven, the developmentally disabled and certain other patients.
  5. 10123.21: Mandated benefit for surgical procedures for jawbone conditions (TMJ).
  6. 10123.5: Mandated benefits for comprehensive preventive care for children age 16 and under in accord with certain guidelines established by the American Academy of Pediatrics (applies to group policies only)
  7. 10123.8: Mandated benefit for breast cancer screening, diagnosis and treatment, including prosthetic devices and reconstructive surgery.
  8. 10123.81: Mandated benefit for mammograms.
  9. 10123.82: Mandated benefit for prosthetic devices to restore a method of speaking incidental to a laryngectomy.
  10. 10123.83: Mandated benefit for prostate cancer screening/diagnosis
  11. 10123.88: Mandated benefit for reconstructive surgery, as defined.
  12. 10123.16: Mandated benefit requiring any policy providing coverage for long-term care facility services or home-based care to cover persons with certain degenerative illnesses, including Alzheimer’s disease (except for pre-existing conditions.)
  13. 10123.18: Mandated benefit for annual cervical cancer screening test if policy includes coverage for treatment/surgery of cervical cancer.
  14. 10123.20: Mandated benefit for all generally medically accepted cancer screening tests.
  15. 10123.68: Mandated benefit for a second opinion when requested by insured or health professional treating an insured.
  16. 10123.89: Mandated benefit for testing and treatment, including formulas and special food products, of phenylketonuria (PKU)
  17. 10123.184: Mandated benefit, in certain policies which provide maternity benefit, for participation in the Expanded Alpha Feto Protein (AFP) prenatal testing program.
  18. 10123.185: Mandated benefit for services related to diagnosis, treatment, and appropriate management of osteoporosis.
  19. 10123.195: Mandated benefit requiring any policy providing prescription drugs to cover drugs, which are prescribed for a use that is different from the use for which the drug has been approved by the FDA.
  20. 10123.195: Mandated benefit requiring any policy providing prescription drugs to cover a a variety of FDA approved prescription contraceptive methods.
  21. 10144.5: Mandated benefit for diagnosis/treatment of severe mental illnesses (adults and children) and serious emotional disturbances of children.
  22. 10145.4: Mandated benefit for routine patient care costs related to cancer clinical trials.
  23. 10176.61: Mandated benefit for equipment, supplies (including prescriptions if prescription coverage is included), and self management training for the management and treatment of diabetes.
Health Access California promotes quality, affordable health care for all Californians.

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