Finally, Insurance Reform That the President Can Sign

It’s hard to believe, for Americans have been fed so many empty promises about health care in the past four years, but Congress may be on the verge of sending the president a health insurance reform bill he can sign.

After a logjam over how to test the GOP idea of tax-free medical savings accounts was broken last week, ebullient congressional leaders said they hoped to have a bill on President Clinton’s desk by the end of this week. Aware of opinion polls showing that voters are increasingly frustrated with the lack of legislative achievement in Washington, lawmakers are clearly eager to get something passed this year.

If the nation is to see genuine reform rather than election-year posturing, a conference committee crafting the final bill will have to make some bold decisions. In particular, it must resolve differences in separate health insurance reform bills passed earlier this year in the House and Senate.

The principal differences concern “portability,” how to guarantee insurance for workers with previous medical conditions; and mental health parity, whether to require employers to offer workers the same financial cap on mental health coverage that they impose on physical health coverage. How the committee resolves the disagreements on these issues will determine whether the bill is true, if incremental, reform.

* Portability. Neither the House nor the Senate bill offers what America’s health care system ought to provide: a guarantee that all citizens have the chance to purchase health insurance regardless of their medical condition. Both bills do, however, offer the assurance that workers who are dismissed or change jobs will be able to obtain individual health insurance, providing they have worked at their former jobs for at least 18 months.

What the conference committee has to decide is whether insurance companies should be allowed to establish a separate policy category for workers with previous health problems (as Republican leaders advise) or whether they should be required to offer these workers rates comparable to those offered in standard policies (as the Senate bill requires).

The conference committee should take the latter course, for if less healthy workers are ghettoized into a single policy group, the policyholders in that group will be forced to pay astronomically high premiums.

Republicans correctly argue that insurance rates might rise for all if some Americans with preexisting conditions are allowed into the general health insurance pool. But a central tenet of all American insurance is shared risk: For decades, for example, mature and experienced drivers in Los Angeles have been paying higher rates so that auto insurance policies can be priced within reach of the incautious young.

* Mental health parity. The Senate bill requires health insurance plans to allocate the same resources for mental health care as they do for physical health care. Because some legislators argue that this provision would coddle those seeking comfort for the ordinary emotional bumps and bruises of life, conferees will be tempted to delete it.

A better course, however, is to sharpen the legislation’s definition of mental illness. Sens. Paul Wellstone (D-Minn.) and Pete Domenici (R-N.M.), for instance, have suggested a focus on widely recognized conditions like chronic depression. Moreover, “outcome studies,” which gather information from insurers, drug companies and hospitals, could help determine which treatments are most effective.

Even without any restrictions, the Senate’s parity provision would not send costs soaring as high as its opponents have claimed. The Congressional Budget Office estimates that the provision in the Senate bill would raise managed care costs by no more than 4%. In contrast, the annual costs to the U.S. economy of one type of untreated mental illness alone--depression--are nearly $44 billion, according to a 1993 MIT study.

The bill that Congress hopes to present to President Clinton won’t solve the problem that first sparked the health care debate in 1992: how to cover the uninsured. But by maintaining the legislative provisions for portability and mental health parity, the conference committee can at least ensure that Americans finally see some measure of real reform.