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Loophole would allow health coverage limits

/ Source: The Associated Press

A loophole in the Senate health care bill would let insurance companies place annual dollar limits on medical care for people struggling with costly illnesses such as cancer.

Adding to the confusion, the language is tucked away in a clause of the bill captioned "No lifetime or annual limits." Advocates for patients say it fails to deliver on that promise.

"The primary purpose of insurance is to protect people against catastrophic loss," said Stephen Finan, a policy expert with the American Cancer Society Cancer Action Network. "If you put a limit on benefits, by definition it's going to affect people who are dealing with catastrophic loss."

Democrats on two key committees disagree on the issue of annual limits, and it hasn't been fully resolved as the Senate presses ahead on President Barack Obama's health care overhaul.

The legislation that originally passed the Senate health committee last summer would have banned dollar limits on medical coverage, but a second panel — the Finance Committee — disagreed. Finance Chairman Max Baucus, D-Mont., and others feared that an outright ban could drive insurance premiums higher for everyone, and sought to strike a balance.

As currently written, the Senate Democratic health care bill would permit insurance companies to place annual limits on the dollar value of medical care, as long as those limits are not "unreasonable." The bill does not define what level of limits would be allowable, delegating that task to administration officials.

"An important goal of reform is to ensure health insurance premiums are affordable," said Erin Shields, a spokeswoman for Baucus. "Senators want to ensure this provision provides as much consumer protection as possible while keeping premiums affordable, and they'll continue to review this policy closely as the process moves forward."

The 2,074-page bill would carry out Obama's plan to revamp the health care system, expanding coverage to millions now uninsured and trying to slow budget-busting cost increases. A tentative deal among Senate Democrats to back away from creating a new government program to compete with private insurers appears to have overcome a major obstacle to passage.

But Finan said the change in the Senate bill essentially invalidates the legislation's ban on lifetime limits.

"If you can have annual limits, saying there's no lifetime limits becomes meaningless," he said. The cost of cancer treatment can exceed $100,000 a year. A patient battling aggressive disease in its later stages could exhaust insurance benefits.

"If you are a cancer patient you could be faced with a situation where you either have to terminate your care, or face a financial catastrophe," said Finan. "We see this kind of situation with some regularity."

It's unclear how widespread such coverage limits are in the current insurance marketplace. Large employers have moved away from limits, but insurers have wide discretion in designing plans for small businesses and individual customers.

In the House bill, neither annual nor lifetime limits would be allowable under an essential benefits package intended to provide comprehensive coverage.

Advocates for patients are concerned the language in the Senate version will make into the final bill, all the way to Obama's desk.