Legislators lack data when requiring coverage

By Mark Pazniokas, the CT Mirror

On the same day last year, the state House of Representatives took up two bills that mandated increased health insurance coverage for various medical conditions.

One passed nearly unanimously and was celebrated by Gov. M. Jodi Rell at a bill-signing ceremony. The other divided the House along party lines and provoked a veto.

The successful measure came with a compelling story about parents' struggles to help their autistic children. The other involved colostomy supplies, wigs, hearing aids and prosthetics.

"Sometimes we vote with our hearts, and that's not always a bad thing," said House Minority Leader Lawrence F. Cafero Jr., R-Norwalk. "Philosophy? I'm not sure there is one."

Over the years, the Connecticut General Assembly has passed nearly 60 laws mandating coverage of various conditions by group health insurers. It is a process without standards.

So how do legislators decide?

"We had no rational basis," said Rep. Steve Fontana, D-North Haven, co-chairman of the Insurance and Real Estate Committee.

"It's an interesting question," said Sen. Sam S.F. Caligiuri of Waterbury, the ranking Republican on the committee. "That's one I've been struggling with for a while."

Sometimes, it comes down to who has a story.

Last spring, Rep. Russell A. Morin, D-Wethersfield, worked both chambers, telling colleagues about a constituent whose skin is sloughing off due to an extremely rare disease, epidermolysis bullosa.

Could they support a mandate for coverage of bandages?

By a vote of 139 to 3 in the House and 35 to 0 in the Senate, the answer was yes.

"Having it covered was clearly going to help people," Caligiuri said. "On the other hand, the number is so small that the mandate wasn't going to be material in driving up health costs."

So, cost is a factor -- but not consistently.

Rell cited cost in vetoing a bill that would have created a new mandate for the coverage of prosthetics and expanded other coverage, including hearing aids for children, wigs for persons who lost their hair due to alopecia, as well as patients who need colonoscopies and colostomy supplies.

"Each of the provisions has merit and would provide additional benefits to people with serious medical conditions," Rell said in her veto message. "Each, however, also will have a significant cost for taxpayers, policyholders, and employers in future years."

A study commissioned by the Insurance Department recently concluded that the cost of the bill would have been 72 cents a month for every policy holder, 35 cents of which would be for the prosthetics.

Colostomy supplies would have cost a penny a month.

But cost did not discourage legislators or Rell when it came to a bill mandating coverage of screening and treating autistic children.

"Families coping with autism spectrum disorders need and deserve this coverage," Rell said at a bill-signing ceremony. "More importantly, children struggling to break through the barriers erected by these disorders need and deserve this hope and support."

The autism bill wasn't part of the Insurance Department's study, but legislators, the Office of the Heathcare Advocate, representatives of insurers and businesses all agree that the cost of the autism mandate was significantly higher than the vetoed measure. "So many people are affected by it, you clearly understand it could drive up [insurance] costs," Caligiuri said. Sen. Jonathan A. Harris, D-West Hartford, the co-chairman of the Public Health Committee, said the advocates of the autism bill made a case that better screening could lead to early intervention and more effective treatment, saving money over the long run. He voted for the autism mandate, but not the measure vetoed by Rell. Cafero said there was another reason why the autism bill passed without significant questions or opposition: Nearly everyone in the General Assembly knows a parent with an autistic child. "You hear these stories, they rip at your heart," Cafero said. "The problem is we isolate these things one by one, then we vote with our hearts - autism, in vitro fertilization, drive-by mastectomies." No one adds up the costs, he said. "It is all our faults," said Cafero, one of 15 House Republicans to vote for mandatory fertility coverage in 2005. "It is our collective fault." Kevin P. Lembo, the state healthcare advocate, said the legislature has a legitimate role in determining coverage. "But the legislature should not be making coverage decisions based on anecdote," he said. "The process is sometimes troubling." The review of the vetoed bill is the first step to trying to establish cost standards, he said. A follow up study of all health-insurance mandates by the University of Connecticut Center for Public Health and Health Policy will be delivered to the legislature in January 2011. All proposed mandates also will be reviewed by the UConn center for cost impact, and that will give legislators a rational basis for assessing new mandates for the first time, Fontana said. Keith J. Stover, a lobbyist who represents the Connecticut Association of Health Plans, called the new review process "a major step." "It's a fundamental recognition that as you address benefits, you address cost," he said. "I take as a very encouraging sign that the legislators and governor are recognizing there are cost implications for mandates." Eric George, a lobbyist on health issues for the Connecticut Business and Industry Association, said arguing against mandates always has been difficult. Arguing costs against the impact on legislators' constituents seldom is persuasive, he said. "It's where your heart strings are being pulled," he said. Caligiuri said the data never has been clear about the true costs of mandates. "It's almost dogma that mandates drive up cost, drive up cost. Yet no one can help me understand how they do," Caligiuri said. He said he invited insurance company actuaries to make the case, and they failed. "There were other factors much more significant," he said. One is that the state's low Medicaid rates force medical providers to recoup their losses by billing insured patients at a higher rate, he said. "That right now is the biggest cost driver," Caligiuri said. "It is not mandates." Rep. Karen Jarmoc, D-Enfield, is co-sponsoring a bill this year that would clarify coverage for hemophiliacs, so an insurer could not force them to order drugs by mail. Waiting for drugs by mail was compromising the quality of care, she said. "To me, that's no OK," she said. "You stand up." But Jarmoc, a self-described fiscal moderate, said she consulted with insurers, consumers and physicians as she and Rep. Matthew J. Conway Jr., D-Windsor, crafted a bill to help a Suffield resident. "It was not a bill submitted off the cuff," she said. Fontana said sometimes legislative prodding is necessary for insurers to simply be more flexible. Legislators intervened with a bill when some insurers covered intravenous chemotherapy for cancer patients, not newer oral versions, he said. Rep. Elizabeth B. Ritter, D-Waterford, the co-chairwoman of the Public Health Committee, said no one should be surprised the process has few standards. Constituents are free to petition their legislators on any issue, including health needs. "The political process is ad hoc," she said. "And the way we do this in Connecticut is the political process."