Abigail Trafford (The Post)

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Nearly 40 million Americans have no health insurance. With a shaky economy, more people are losing their jobs and their health coverage. Last week, a coalition of 12 leading business, labor and health organizations signed a proclamation to find solutions to this problem. Have you ever had a problem getting health coverage? Are your benefits being cut back? Are you spending more "out of your pocket" for medical services?

Welcome to Health Talk with Post Health columnist Abigail Trafford. To discuss health insurance problems is Charles N. Kahn III, president of the Federation of American Hospitals.

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Abigail Trafford: Wave a magic wand. What solutions would you put in place TODAY?

Charles N. Kahn III: I personally would like to see all Americans covered by insurance. However, I beleive we have to be practical. The political stars are not aligned to have that happen today. so, we need to think incrementally.

Abigail Trafford: A key issue is that health coverage is so expensive. There are laws that enable people who lose their jobs to continue their health coverage--COBRA. But it's often not affordable. Talk a little bit about the problem of affordability and how this can be addressed.

Charles N. Kahn III: You have hit on the key issue. Affordability. the fact is two thirds of the uninsured lack the wherewithal to purcahse coverage. Whether it is through public programs or tax policy, they have tobe subsidized to get coverage.

Abigail Trafford: Hello and welcome. You have been part of the health care scene for decades. There have always been millions of Americans who lack health coverage. Why is the problem so urgent now?

Charles N. Kahn III: During the good times of the last few years the number of uninsured Americans was too large, but at least decreasing. That decline has ended and now a bigger number is going to get beigger. There is no question that the health of people is effected by whether or not they have coverage.

Big Pine Key, Fla.: Should all Americans have a basic, fundamental level of health insurance?

Charles N. Kahn III: I firmly believe that individuals need basic hospital and doctor coverage. After that I would not want to have the debate over the benefits kill the prospect of getting people anything. Now many will dispute this and want to have it all specified in law. but, I think that is impractical. It will lead to poison pills that kill any legislative endeavor.

Washington, D.C.: When you were president of the Health Insurance Association of America, you and some other organizations were backing a public-private sector plan called InsureUSA to extend access to those without healthcare. Are you still in favor of this sort of solution and does the Bush administration and Congress seem predisposed to it?

Charles N. Kahn III: With the political controls in Washington so evenly split, even with a Republican in the White House, I believe that only a proposal accepts some public program expansion with tax proposals that subsidize private insurance can ever pass. All that said. We saw the health provisions of the recent stimulus package go down partly becasue the two political sides could not come together on public versus private approaches.

Harrisburg, Pa.: States will be allowed to expand their children's health insurance programs to include coverage for pregnant women without health insurance. Yet, some analysts note state budgets will not have the funds to pay for such expanion. Do you have any thoughts on this?

Charles N. Kahn III: The states are in a bad way fiscally right now. That is not good for health coverage. But, so much is tied to the economy. If the economy gets moving again, that would solve some of this problem. This is a fiscal not a health issue really.

Arlington, Va: Although the folklore would indicate that people with good insurance are treated better than people with bad insurance, I think everybody seems to be treated badly in hospitals, kept up all night for no reason and then lectured in the morning for looking bad.

Abigail Trafford: What people want is access to quality care. Having insurance increases the chances that you will get that--but doesn't guarantee it. People without health insurance are known to have more untreated medical problems and are at risk of dying prematurely compared to the insured. Chip, explain why not having health insurance is bad for your health? And secondly, do you have any tips of how people can get quality care once they get to the hospital?

Charles N. Kahn III: Every study and common sense tells you in this country if you have health coverage, you are more likely to seek the care you need when you need it. Without coverage, people avoid until they are sicker than need be or worse.

As to hospital care, the shortage of nurses and other professionals has had an effect, but they generally get the job done nonetheless.

Anywhere, USA: Thanks for taking my question - I don't want to go to HR, because they'll know I'm planning to leave! My husband and I are planning to try to get pregnant soon. I currently work full time with my own health insurance. I want to quit my job when the baby comes to stay at home. Should I switch to my husband's health insurance before I get pregnant? Will they let me do that in the middle of the year? Or should I keep my own insurance and switch just before I quit my job, which would be toward the end of the pregnancy? Thanks for your help.

Charles N. Kahn III: Boy, I am not in a position to give personal advise. However, I can say generally if you have a major change in employment, i.e. you leave or lose your job, the other employed spouse's insurance will usually pick you up with out a waiting period. But, there is variation here, so be careful!

Los Angeles, Calif.: Why is there no discussion of the findings of the report (Daily Health Policy Report: Coverage and Access - Many Uninsured California Latinos Find Health Insurance 'Too Expensive' or 'Not Necessary,' Study Says -Oct 05, 2001) that suggests that a substantial percentage of Hispanic "uninsureds" (13%) are that way as a matter of choice?

And what of those "uninsured" who report that insurance is "too expensive"? How is that decision made? Do I have the right to make that decision also? I pay more than $4000 per year. That's certainly "expensive."

Charles N. Kahn III: You site an important problem in a voluntary system. Some people do the right thing while others do not, and that hurts those that do. However, most of the uninsured are under 200% of poverty (something like $28,000 for a family of 4). So there is a strong relationship between income and affordability by anyone's definition. But, your point does lead some to conclude that coverage should be mandated.

Seattle, Wash.: I'm unemployed, pregnant, and paying my own health insurance premium to Blue Shield. Fortunately, I am able to afford the $100/month premium, and my insurance pays 80% of expenses after I pay a $500 deductible, which is not bad, I suppose. But it worries me that if something happens either during my pregnancy/ child's birth or if I'm in an accident, I will be in over my head with medical bills. My husband works for a small business, and if he were to add me to his plan, he says his monthly payment would increase to $400 because of the pool of employees being insured (they're all much older, in their 60s, with chronic health problems).

Right now it seems difficult to find a plan that is suitable and affordable for people like me, who are stuck in the middle. Here in Seattle we have a basic health plan for people of lower income levels who can't afford high premiums -- it's about $20 a month, I believe. But it covers the most basic needs, and those who exceed the income-level requirement are on their own. Is there anything else that I can do to keep my costs down?

Charles N. Kahn III: These are tough questions. I am going to take a risk and be blunt. Health care is expensive, hopefully people will have coverage for most of the cost. But, it is very difficult to insure everyone first dollar and last. As a society, there is just not enough money that people are willing to spend to do that.

Baltimore, Md.: I thank you for your mention in your column today that eight of ten uninsured Americans works. I think too many people have the wrong impression of the uninsured & think they're slackers looking for a handout, when in fact the opposite is true more often than not. I have insurance now, but for a few years after I finished college, when I was in my $8 an hour temp job phase, I did not. I wonder how many of the uninsured fall into that age bracket, since generally you're dropped from your parents' policy when you graduate, & a lot of people aren't lucky enough to get jobs with benefits right away. I feel as though that is probably a seriously underserved population, insurance-wise. Even a one-person policy for a healthy person costs about $200 a month, which is waaaaaaaay more than someone who takes home $200 a week can afford.

Abigail Trafford: You are in a high-risk age group when it comes to health insurance. The good news is that as a general rule you are a very healthy population. You soon get established in the workforce and have access to coverage on your own. But there are exceptions and many people are vulnerable. Chip, what should people who are fresh out of college do to make sure they have health insurance?

Charles N. Kahn III: Most Americans right out of college are healthy and at low risk of needed health services. They fall in one group that can usually go to the web and find affordable individual coverage. That ought to tide them over until they get more comprehensive coverage through their employment. Also, some parents will be able to keep their recent grad children on their coverage until they reach 25 or are otherwise covered at work. People are to check out that opportunity.

Big Pine Key, Fla.: When the political stars were alligned for national health insurance under the Clinton administration, the medical, hospital, and insurance industries were instrumental in poisoning the atmosphere against it, and you, Mr. Kahn, were a part of the poisoning. Has anything changed in your mind? What would you do differently?

Abigail Trafford: Ah. Tell us about the Harry and Louise ads. . . . And what would you do differently today?

Charles N. Kahn III: Actually, I feel the same. I thought we needed taxpayer help for those who could not afford coverage then and I think we need it now. However, in '93 there were some health reform ideas being floated that would have set the whole system back in my view. Harry and Louise wanted to see more Americans covered. The Adminstration at the time wnated to see it done their way and were inflexible. They could have had progress, that is my view anyway.

Seattle, Wash.: Chip, this "strange bedfellows" initiative with HIAA and Families USA which this derives from was developed at a time when we had money in federal and state budgets. In our state right now we are cutting existing Medicaid programs; so there would be no room to expand, even with 30,000 people here who are losing their jobs with Boeing. So the public expansion of this initiative is not very realistic now. The original quid pro quo was one group would support public program expansion, if the other would support a tax credit. But, with Medicaid programs being reduced in so many states, how can this work? More federal money for Medicaid programs? Where would the states be on this?

Kathleen O'Connor, author, The Buck Stops Nowhere: Why America's Health Care is All Dollars and No Sense; publisher, The O'ConnorReport.

Charles N. Kahn III: You ask a tough quesition. The States have always been reticent about mandates from DC. Our proposal assumed expansions that would have cost them money, even with additional federal spending. It will be tougher now. Maybe it means we have to be more modest in our expectations. But, I see no other way to make progress.

Vienna, VA: Health insurance began to be used to finance health care in the 1930s. Do you still believe that this is a superior way to finance health care or should we consider other models?
If so, what should these models look like?

Charles N. Kahn III: I believe that American people want a private health care delivery system. So, you need insurance, whether private or public to pay for it. That means people have to be put in pools of sick and well people, I see no way around that. A public program has a bigger grouping but its all the same to me from the standpoint that insurance will underlie the system.

Washington D.C.: Are there any laws at the federal, state, or local level limiting the reasons health insurers can cancel an individual's policy?

If someone with health insurance develops a chronic illness like MS, depression etc., can their carrier non-renew their policy?

Abigail Trafford: Chip, what is the law on medical underwriting for health coverage. I thought that insurors could not disqualify individuals for a medical condition if they were in a group plan. But that still leaves people who seek individual policies. What can they do?

Charles N. Kahn III: Regulation of underwriting does vary from state to state. But, overarching federal rules in ERISA and the Health Insurance Portabiltiy and Accountability Act pretty much require guarantee issue to all employer groups. Most states also regulate rates. Accessability to insurance is dependent on having a policy to buy but also on the affordability of that policy.

Washington DC: I was recently diagnosed with depression and prescribed anti-depressants, which I only took for a short time. Now I am concerned that I may be turned down for insurance at a later date because of this history. I have been in great health otherwise, and am only 32. Can an insurer contact a previous insurer to get a medical history? Ie., if I don't tell another soul, could a new company find out? What are the prospects for lessening the stigma of mental illnesses when considering health care coverage?

Thank you.

Charles N. Kahn III: Here again, I have to answer in general. Generally, as long as you continue coverage you can avoid underwriting, people looking at your history, or waiting periods for conditions that may be pre-existing before you took new coverage. If you have a major break in coverage there are circumstances for individual coverage where medical history may come into play. But, usually, you are looking at a waiting period, at worst.

Kingstowne, Va.: Currently lost in health care coverage limbo: old coverage lasts until 2/28, new coverage supposed to start 3/1. Now new employer's agent is DEMANDING certification of prior coverage before they'll process my paperwork. Waiting for HR to figure it all out.

But am noticing that more & more doctors & dentists aren't taking ANY insurances. Just got stuck with a $250 gynocologist bill because they decided the week before my visit not to accept my insurance. And didn't tell me until AFTER the visit. My dentist no longer accepts ANY insurances - it's a pay up front & hope for reimbursement. It's annoying & frustrating - pay all this money for premiums & then be told "Well, we won't pay for it anyway, even though it's covered, because of Reason X or Reason Y."

Abigail Trafford: You've raised a key issue. More and more doctors and dentists aren't taking any insurance. They charge their rates and then tell the patient to get reembursement. Usually their rates are higher than what the insurance company allows. The patient gets stuck with a huge proportion of the bill. What can be done about this?

Charles N. Kahn III: Providers cannot generally be required to accept insurance. There is nothing much that can be done here. Frankly, costs are going up, and one way to keep the premiums down is to pay providers less. The providers have rebelled, and that is what we are seeing here. This may not get any better. This is one of the issues caused by ever rising health care costs.

Northern Virginia: Why is health insurance so different from other types of insurance? The cost for a self-employed individual to cover themselves and their family is astronomical, even taking into account the lack of employer contribution. I understand that participating in a group plan spreads the risk over a number of subscribers, but doesn't the same apply to my homeowners and car insurance, which I purchase individually?

Charles N. Kahn III: Group coverage does spread the risk. But, much health coverage is accompanied by an expectation that you will use the coverage. In a sense, it is frequently more a pre-payment concept than an insurance concept. This makes it more expensive. You don't plan to use your car insurance, so this kind of insurance is true insurance.

Washington, D.C. : I'm not entirely pro-gov't. here, but i think having uninsured or uninsurable people is a free market failure. People's lives & health count for more than a bottom line profit.

Is there some insurance you can buy to protect yourself from a catastrophic or terminal illness? How is it valued? thank you.

Charles N. Kahn III: Americans don't seem to value catastrophic coverage or high deductible coverage. Unfortunately that is true insurance and much more affordible. I don't see a market failure here, I see an expectation failure.

The fact is that few of us use most fo the health care dollars but many of us use some of them, and it is hard to fund that at a reasonable level.

Buena Park, Calif. How can I buy a cheap health insurance policy for five members of my family, myself age 55,spouse 41 and sons 19,18 and 11 years. My source of income is very low - it is just hand to mouth. A health policy that covers all. All of my sons are full-time students. We can hardly afford a health insurance policy. Please guide us.
Thanks.

Abigail Trafford: This is really tough. The most affordable health insurance for families is found through group coverage, usually through the workplace. Individual policies are much more expensive. There are also public programs that vary from state to state. The government SCHIP program for children includes parents in some states. Chip, what would you do in this situation?

Charles N. Kahn III: I go back to true insurance. You can't find first dollar coverage for your situation outside employment. But, as long as you are all well now, you should be able to find a high deductible policy, maybe $2,500 or a bit higher. This is not perfect. Newvertheless, if anyone got really sick, this could be a life saver for your family.

Alexandria, Va: Do you know anything about the laws on whether insurance plans have to offer coverage for birth control the same as regular prescription drugs?

I'm interested in the subject and I have not had much luck searching for the exact laws in Virginia. Is this an issue that would have separate laws state-by-state?

Charles N. Kahn III: This is pretty much state by state in terms of mandates on benefits. Unfortunately, I don't know the Virginia law, but anyon selling insurance that covers drugs ought to be able to tell you or ask a pharmacist. The pharmacists ought to know what is generally covered in a state.

Vienna, Va.: Thanks for taking my question:
Why is it that we are focusing on ensuring [that] folks have health insurance coverage instead of focusing on the price of health care products and services and how reasonable those prices are (or are not)?

Abigail Trafford: You're absolutely right to raise the issue of costs. Without some controls/incentives to restrain prices in health care, there will never be enough insurance coverage to pay for medical services. Until now, it's been left to the marketplace to hold down costs and make services more efficient and effective. But that hasn't happened. Costs are rising, costs of insurance are rising, more people are without insurance. Isn't it time for some draconian measures. Like government action and some form of national health insurance?

Charles N. Kahn III: It is great to fantasize about some great governmental hand that will cut all the costs and make it all efficient. The two have never gone hand in hand. No, I would be concerned to see the blunt hand of government. We have that in Medicare. It works sort of okay for inpatient hospital payment but has been a disaster for phyicians and may other doctors. We have to face it. You can always squeeze out some costs, but at the end of the day health care is expensive.

Vienna, VA: In line with the question about use of health insurance to finance healthcare, what are your views on defined contribution plans- won't this require us to make decisions about what "defined benefits" we should offer?

Abigail Trafford: (And please explain what "defined contribution plans" are.)

Charles N. Kahn III: Defined contribution is simply a way to spread cost increases to employees. I would not argue against it, but we need to be honest about that.

Abigail Trafford: Hello everybody. Our time is up. Sorry not to get to all your questions. Thank you Chip Kahn. Thank you all for your comments. Next week we'll talk about cloning your pet. The technology is here--but is it a good idea to use it? Join me next week for another Health Talk.

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