Congress may get tough medicine from health bill

No matter how the case turns out, one group of Americans is assured of getting quality health insurance when the Supreme Court rules on President Obama's Affordable Care Act in June: members of the court itself.

The Supreme Court, which is expected to issue its decision in June, gets its health insurance through the same plan available to members of Congress and other federal employees — and though benefits have been trimmed in recent years, it remains among the best.

In one little-known feature of the law, however, members of Congress would have to leave the generous federal plan and obtain their coverage through online insurance exchanges, or markets, if the law is upheld. The law mandates the establishment of exchanges in each of the states as a means for consumers to shop for health coverage, comparing costs and features of competing plans.

"It is more of a gesture to show that members of Congress are willing to experience what ordinary Americans are willing to accept," said Mark Pauly, professor of health care management at Wharton, referring to the requirement that Congress exit the federal employee health plan.

The federal government spends some $50 billion a year to provide health care coverage to eight million federal workers, retirees and their independents under the Federal Employee Health Benefits Plan. Expanding it to include nonfederal workers has been touted as a way to fix the nation's twin health care ills of spiraling costs and growing numbers of uninsured. A total of 225 health insurers and health maintenance organizations participate.

"The actuarial value of these plans is very good," said Walt Francis, an economist and program analyst who writes the Consumers' Checkbook guide to federal health care coverage, a website that compares costs for federal employees in every region of the country. "In years past, it [the federal health care plan] was arguably inferior on average to large employer plans. But those have been cutting back and now the two are very comparable on average."

The fact that members of the Supreme Court have health insurance should come as no surprise, nor does it have any legal bearing on the complex issues before the court. The case, brought by 26 Republican attorneys general and the National Federation of Independent Business against the Obama administration, hinges on whether the federal government has the power to require individual citizens to obtain health insurance or pay a penalty to the IRS, as part of a larger plan to extend coverage to millions of uninsured Americans.

But the controversial law illustrates the political and policy complexities that face lawmakers and executive branch officials trying to extend coverage to the uninsured. Jurists also face difficult choices sorting through the competing arguments.

"They are pretty decent plans," said Pauly, of the federal health insurance plan. Pauly asserts one reason federal health plans offer relatively generous benefits, and stack up well against those in the private sector is that federal workers on average are paid less than private sector employees; the difference is made up in benefits.

Depending on the type of plan, out-of-pocket costs for federal employees in the Washington area, which would include members of the Supreme Court, range from $2,410 to as much as $7,930 for a family of four, including deductibles and co-payments. The Checkbook website estimates that a basic Blue Cross plan would cost the typical family of federal workers about $4,300 a year, including deductibles of $25 for visits to the doctor and hospitalizations with $150 a day deductibles.

The coverage typically resembles plans provided to private sector workers, and with good reason. Participants in the federal plan include some of the nation's largest private insurers, Aetna, Blue Cross and Kaiser Permanente, among others, who also contract with large private employers.

Under the basic Blue Cross option, there is no overall deductible. But, the plan imposes penalties on patients who fail to abide by its cost-cutting strategies such as obtaining advance approval for a hospital admission. Failure to get such an approval, for example, could result in a $500 charge. And if a patient chooses a hospital outside of the insurer's network, the patient risks paying the entire cost of the hospitalization out of pocket.

Because the federal health insurance plan has been successful in holding down costs, it also has been touted by liberals and conservatives as a potential vehicle for providing coverage to the nation's uninsured, now totaling around 50 million. When he ran for president in 2004, Sen. John Kerry (D., Mass.) proposed opening the program to uninsured Americans who could not afford to purchase coverage on their own but earned too much to qualify for Medicaid, the government-financed health care program for the poor.

The federal employees health insurance plan, which served as a model for the exchanges, would not be impacted if the Affordable Care Act is upheld. The only change would be the requirement that members of Congress exit the plan and obtain coverage from the exchanges. The exact details of how members will purchase insurance, and from which exchanges, have yet to be worked out.

But Joseph Antos, a health care policy analyst at the American Enterprise Institute, a conservative think tank based in Washington, said that language was inserted by Republicans to make a point.

"The reason that provision was adopted was purely political," Antos said. "It was purely for Republicans to say to Democrats that if you like this so much, you should live with it too."

Contact Chris Mondics at 215 854 5957 or cmondics@phillynews.com