Editorial: Some insurance benefits are essential

The House of Representatives last week postponed voting to gut Obamacare after new provisions weakening the essential benefits guarantee failed to win support from right-wing Republicans, who are opposed to any form of subsidized health insurance.

Suffice it to say that the last-minute maneuvering clarified how far the modern Republican Party is willing to go in undermining health insurance, and the healthcare system along with it.

They want to do away with major medical insurance, and return to the 1950s when most people only had hospital insurance, or what we now call catastrophic coverage.

This is not conservative in the institution-preserving sense of 18th century British statesman Edmund Burke, who is considered the father of conservatism. Nor is it the practical politics that even very conservative Republicans practiced until about the mid-1990s.

What we're seeing today is an extreme brand of reactionary politics, defined by Wikipedia as a person or movement that “holds political views that favor a return to the status quo ante, the previous political state of society.”

I would prefer spending the space I'm offered each week opining about value-based reimbursement, population health, dealing with the behavioral health and substance abuse crises (this week's cover story), or tackling the social determinants of health.

But the election results of 2016 put a person in the White House who appears to neither care nor understand any of those issues (“it's complicated”). That empowered the most reactionary members of Congress to run roughshod over the basic social contract that has governed our healthcare system since the mid-1960s.

Let's return to the supposedly halcyon days of 1960. Just 32 million of the 142 million people enrolled in private health insurance plans had major medical coverage, which covers routine care. The 700 insurance companies selling those plans did not offer maternity care. Physician visits weren't paid for. Drugs weren't covered.

All of that began to change in the 1960s with the advent of Medicare and Medicaid. Employers began including major medical in their plans. By 1980, nearly everyone with employer-based coverage had coverage for a substantial share of their nonhospital medical bills.

That wasn't true in the individual insurance market, though, where insurers were free to offer plans that looked like pre-1960 plans. That might have been a good deal for relatively healthy individuals able and willing to absorb the upfront costs of routine care.

But it made insurance for those with serious illnesses unaffordable. It left most low-income working people whose employers didn't provide coverage without access to physician services except in an emergency. And, as low-wage work without benefits proliferated, it eventually left 16% of working age adults uninsured.

The Obama administration surveyed insurers selling individual plans shortly after passage of the Affordable Care Act. It found 62% of available plans did not cover maternity services; 34% did not cover substance abuse services; 18% did not cover mental health services; and 9% did not cover drugs.

The ACA established 10 essential benefits that had to be covered by individual plans sold on the new exchanges. They included ambulatory care, emergency care, hospitalization, rehab, labs, prevention and pediatrics, as well as the four already mentioned.

More expensive? Yes. But with everyone in the pool, it was affordable for lower-income people if given subsidies.

Allowing Congress to turn back the clock in the individual market will set the stage for employers to do the same. History shows that corporate America usually follows the government's lead when it comes to health insurance design. They've already set the table by putting 30% of their workers in high-deductible plans.

Providers facing patients with only catastrophic coverage will have no incentive to manage the health of groups or to continue experiments with value-based reimbursement. Taking health insurance back to the 1950s would deal a devastating blow to the movement to achieve higher-quality, lower-cost and more-patient-centric care.