What constitutes coverage?

As the Democratic presidential candidates debated whether their “universal coverage” plans were “universal”–and what that meant–there wass surprisingly little debate about the definition of “coverage.”

What makes “coverage” coverage?

It’s a good question, as Florida Governor Charlie Crist just signed a so-called health reform that doesn’t expand coverage one bit, but rather strips down the definition of coverage to make the premium cheaper. Critics say that as insurers water down the benefits, at some point the value of the coverage is so little that it’s not worth paying premiums for in the first place.

It seems people get coverage to prevent the real health and financial consequences of being uninsured. They literally pay a premium to 1) get the care they need, and 2) not face financial ruin as a result.

There are some products out there that don’t meet this basic definition. For example, we’ve heard of products–some sold by disreputable outfits, sometimes on TV at 3am–that say they provide hospital coverage, but only reimburse $200/day. Only if you’ve been to a hospital do you know that such a plan doesn’t begin to cover an overnight stay, and that such “coverage” from a masssive hospital bill is merely an illusion. It’s “junk” insurance.

SB1522(Steinberg), which passed the California Senate Tuesday, would set a minimum standard for coverage as well, in two basic ways:

* It would set an overall cap on out-of-pocket costs, so people paying premiums would not face unlimited financial liability when they get sick or have an emergency. This won’t eliminate your standard high-deductible plans, may be a (not great) option for a healthier, wealthier person who wants to save on the premium and who has the ability to self-insure a few thousand dollars of a deductible. But it would eliminate those plans which cover so little or impose so much cost-sharing on the patient that the person continues to be at risk of banktruptcy.

* It would requires that a plan should include doctor, hospital, and preventative care, preventing hospital-only coverage. This would prevent hospital-only plans that leave patients in a situation where cancer isn’t covered, since most of the treatment is in a doctor’s office, rather than a hospital. Even worse, you don’t want an perverse incentive for people to want the more invasive, more expensive hospital treatment unless they need it. Again, these plans often provide a false security to patients–until its too late.

These “junk” plans, because they collect premiums but are far skimpier in paying out benefits, can be very lucrative for the insurers who sell them. But they have the capacity to undermine the very notion coverage altogether. What’s the point of paying for coverage, if you still face financial ruin?

People are growing more and more concerned that their coverage will not be there for them when they need it. They are frightened that even if they are insured, there will some loophole or provision that leaves them with significant medical debt. That’s why SB1522(Steinberg) and other efforts are so important, to make the definition of coverage mean something. Consumers with coverage deserve some security that with their premium, they will be protected.

Health Access California promotes quality, affordable health care for all Californians.

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