Health Care Heartburn

President Obama's prime-time news conference on Wednesday night was designed, in part, to make the case for immediate health care reform, which is facing some obstacles in Congress. Most of the debate is focused on how much a reform plan would control spiraling health care costs and how many uninsured people it would cover. But lawmakers and advocacy groups continue to discuss health care reform's effect on the Federal Employees Health Benefits Program and its role in finding a solution.

FEHBP long has been part of the health care debate because it preserves enrollees' choice among competing plans and levels of coverage, and its costs are relatively low compared with the costs of operating and participating in private sector plans. During the 2008 presidential election, Democratic candidate Hillary Clinton proposed a version of health care reform that would allow the general public to participate in FEHBP, but would create a separate risk pool to protect federal employees from cost increases that could result if sicker or older participants enrolled in the program's plans. In March, representatives from the Obama administration said they were looking to FEHBP as a model, though they were unlikely to use it as a public option in a reform bill to force competition with the private sector.

On Wednesday, the American Cancer Society Cancer Action Network and the Georgetown University Health Policy Institute issued a report that examined FEHBP from another angle -- as a potential model for the minimum level of coverage insurers would have to provide to participants. The report analyzed how much coverage FEHBP's Blue Cross Blue Shield Standard Option Plan, the program's most popular offering, provides to patients with breast or colon cancer, heart disease or diabetes, and how clearly the plan explains coverage to participants.

The researchers found that Stage II breast cancer patients covered under Blue Cross could pay between $10,000 and $13,000 over two years for treatment, while Stage II colon cancer patients could pay between $15,000 to $17,000 during the same length of time.

They also found that some confusing elements of the plan could lead participants to pay more than they expected for medical care. For example, Blue Cross pays for different amounts of coverage, depending on whether a health care provider participates in their network. The insurer also has preferred providers within the subset of in-network providers, but its Web site does not identify them outright, making it difficult to find the physicians who will receive the highest rate of reimbursement from Blue Cross when they treat plan members, according to the report. In addition, researchers said it might not be clear to participants that enrolling as a family might allow them to pay less out-of-pocket annually than signing up as individuals if both adults are eligible to enroll in the program as federal employees.

"The study shows that the Blue Cross Blue Shield Standard Option plan is 'adequate,' " wrote the reports' authors, Karen Pollitz, Eliza Bangit, Jennifer Libster from the American Cancer Society, and Nicole Johnston from Georgetown. "It offers good protection by covering the most important benefits without caps and with an overall limit on cost-sharing liability. However, it is certainly not 'Cadillac' coverage."

But even if some of the FEHBP options do not provide the best health care money can buy, lawmakers are still protective of the program overall. Rep. Darrell Issa, R-Calif., ranking member of the House Oversight and Government Reform Committee, asked Chairman Edolphus Towns, D-N.Y., to hold hearings on the House Democrats' health care reform bill, H.R. 3200, on the grounds that FEHBP might not meet the standards in the bill for a "qualified health benefits plan." To meet that standard, providers would have to satisfy a number of conditions, including agreeing to cover pre-existing medical conditions, guaranteeing that individuals can re-enroll in their insurance plan unless they have failed to pay premiums, covering mental and physical health treatment the same way, and ensuring that adequate provider networks are available to participants.

"This legislation should not move forward until we know its effect on our federal employees," Issa wrote to Towns in a letter.

On Monday, Towns denied Issa's request to hold hearings, saying the legislation includes a five-year grace period for plans to make changes to meet the criteria for qualified plans, so FEHBP would have until 2018 to make what Towns described as the minor administrative and coverage changes necessary to meet those standards.

Even if Oversight and Government Reform doesn't hold hearings on health care reform, other committees will. And as lawmakers struggle to determine how to cover as many people as possible for the least amount of money, the programs available to federal employees will be in the spotlight.