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PUBLIC
FINANCING
including 12 counties that previously had none. The emergency care Congress to prohibit health insurance companies from excluding
provisions have saved lives by helping ensure Texas patients have coverage for patients with preexisting conditions. Patients need ac-
access to critical and timely care. The 2003 liability reforms have cess to health care coverage, especially when they suffer from an
worked. They’ve lived up to their promise. Sick and injured Texans ongoing medical condition. The PPACA now helps patients who
now have more physicians who are more willing and able to give have a preexisting condition obtain and maintain coverage when
them the medical care they need. they are sick.
The rest of the nation will benefit from Texas-style reforms TMA Ask: Maintain the PPACA provision prohibiting insurance
companies from excluding coverage to patients with preexisting
TMA Ask: New medical liability reforms must measure up to conditions.
the “Texas-size” reforms. New national medical liability reforms
must NOT modify or change reforms now in Texas law. Prohibition on Rescissions
Patients should not lose their health insurance, especially when
Antitrust Relief for Physicians
The Federal Trade Commission prohibits a physician’s ability to they need it most, because of an honest mistake when filling out
health insurance paperwork or applications. Prior to the PPACA,
clinically integrate as imagined by the new health law. The new health insurers could rescind a patient’s insurance policy if they dis-
health law asks physicians to collaborate in ways government has covered an alleged misrepresentation in the patient’s initial applica-
discouraged through antitrust laws. For physicians to clinically in- tion for insurance, even an honest mistake or omission.
tegrate so they provide efficient care as imagined by the PPACA, a
broad, bright-line rule needs to be established so physicians can When coverage is rescinded by an insurer based on a misrepresen-
work together without fear of government discipline. tation on the application, all coverage is rescinded, leaving the patient
responsible for paying for all of his or her health care services past
TMA Ask: Congress needs to provide antitrust relief for physi- and present. Health insurance applications are confusing, and some-
cians so that they can organize to provide cost-effective care and times people make honest mistakes in completing the forms.
be protected from unscrupulous corporations putting profits before
patients. TMA Ask: Insurers should not be allowed to cancel a patient’s
health coverage over technicalities in completing forms.
Direct Contracting
As baby boomers come of Medicare age, increased flexibility in Medical Loss Ratios
Health insurer profits are expressed as part of the industry’s term
Medicare will be necessary to ensure patients have access to a physi-
cian. One way to accomplish this is to allow Medicare patients to “medical loss ratio.” The medical loss ratio is the percentage of pre-
see any physician of their choice. Physicians should be allowed to mium dollars spent on payments to physicians, hospitals, and other
enter into direct contracts with Medicare patients, even when they health care providers for health care services rendered. The pre-
opt out of the Medicare. mium dollars left include health plan salaries and overhead, as well
as profits. Simply stated, insurers can maximize their profits by
TMA Ask: Pass the Medicare Patient Empowerment Act. Give spending less on a patient’s health care.
physicians the ability to directly contract for any and all Medicare
services. Employers and employees are spending more money on health
insurance coverage each year. Yet they have no idea if their hard-
Keep What Works in the PPACA earned premium dollars are going toward health care or else-
where. Prior to the adoption of the PPACA, there was not a
Insurance for People With Preexisting Conditions single definition of a medical loss ratio. This made it impossible
From July to October 2009, TMA conducted 16 town hall-style for employers and patients to compare health plans. TMA be-
lieves a consistent reporting formula for medical loss ratio works.
meetings (aka House Call meetings) on health reform across Texas Now employers and patients can compare health plans with oth-
with more than 3,000 patients and physicians participating. At every ers when shopping for insurance.
meeting, both patients and physicians called on Texas legislators and
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