No, we didn’t just travel back in time. We just went south of the equator. Down in Australia some of the health squabbling right now sounds a lot like what just went down in the U.S.

Australian Prime Minister hit the home stretch on the Aussie version of the health care overhaul bill Tuesday when he got 7 of 8 Australian states to sign onto an agreement with him — leaving just Western Australia in opposition.

Rudd told newspaper: “We’re pretty confident we can work something through with our friends in the west,” but added, “it might take a bit of time, a bit of an arm-wrestle.”

As friendly as that arm-twisting sounds in his Australian accent, the opposition to the legislation there echoes some . Rudd’s plan would require each state essentially to give up the rights to a significant portion of their tax revenue, which would instead be used by the federal government to fund the country’s hospitals.

The Australian health system (actually called ) gives every citizen free access to hospital care and all other care at a subsidized rate. The problem is that the public hospitals are run by the states, and most aren’t in great shape. Overcrowded hospitals, long wait times and doctor shortages are problems there. And Australians have to deal with private insurance companies when it comes to trying to get coverage for unsubsidized out-of-pocket costs.

But the plan to give the feds control over funding led one opposition health spokesman to tell Australian reporters: “Another bureaucracy in health is not going to provide better patient outcomes.”

Colin Barnett, Western Australia’s premier (the official Rudd has to persuade to enact the legislation), says that tax money won’t be given up so easily, calling the plan “not acceptable to me and not acceptable to Western Australia,” according to .

The plan, though widely supported by the other state premiers at this point, is still pretty vague. Rudd has yet to detail how much the program will cost in full and how it will be funded.

Despite that shortcoming, Rudd is busy touting a few popular, immediate effects reform would bring — a move he might have . Those changes would include decreasing emergency room waiting times, adding beds to overcrowded hospitals and funding all primary care services, according to the .

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When Kelly Arellanes fell off a horse and suffered a severe head injury in rural Arkansas, medics said she would need to be airlifted immediately to the nearest hospital-50 miles away in Fort Smith. There, emergency surgery saved her life – but at a cost.

The hospital wasn’t in her insurance network, so she and her husband ended up with $20,000 in out-of-pocket expenses that they wouldn’t have incurred at their network hospitals 150 miles away in Little Rock.

Under the new healthÌýlaw, insurance companies must extend several new protections to patients who receive emergency care. One of the biggest guarantees: Patients who need emergency treatment will have their costs covered at the same rate, regardless of whether they are treated at “in-network” or “out-of-network” hospitals.

The law also bars health plans from requiring prior authorization for emergency services. And it mandates that plans follow the “prudent layperson” rule. For example,Ìýif a person goes to the ER with chest pain, but ends up being diagnosed with indigestion, the claim has to be covered because going to the hospital under those circumstances made sense.Ìý

More Coverage: Health Reform & You

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The provisions go into effect for every health plan issued after Sept. 23 – six months after the law was enacted — that offers emergency coverage.

For years, insurance plans have been denying ER claims for a variety of reasons. Although there is little data on the overall scope of the problem, a 2004 RAND Corp. study found that at least one out of every six claims for emergency department care was denied by two large HMOs in California.

One Hour To Live

When Kelly Arellanes’ husband, David, and daughter, Jo, rushed by car to the hospital after the accident six years ago, the neurosurgeon gave them two options. “He said, ‘You need to make a decision: either we go into emergency neurosurgery now and save her life, or we don’t and she’ll have an hour to live,'” David recalled.

Kelly, who had a portion of her brain removed that day, has since then learned how to speak, eat and walk again. The Arellanes’ finances haven’t fared as well. David and Kelly had health coverage through their jobs at Southwestern Bell Telephone Co., now part of AT&T, one of many large corporations that is self-insured. In such plans, the employer sets the benefits package and pays workers’ claims and benefits itself. Southwestern Bell’s plan was administered by United Healthcare.

Kelly Arellanes and her husband, David. When Kelly fell off a horse and suffered a severe head injury in rural Arkansas, medics said she would need to be airlifted immediately to the nearest hospital-50 miles away in Fort Smith. There, emergency surgery saved her life – but at a cost.(Family Photo)

According to the plan’s 2004 policy guidelines, provided by David Arellanes, emergency claims incurred at an in-network hospital were completely covered, while those at an out-of-network hospital were covered at the “non-network” rate of 80 percent, unless patients contacted their primary care provider within 24 hours.

Arellanes, 56, said he did call to report the accident within the designated period, but that was disputed in an appeals process. Originally, the plan denied coverage for many of the emergency bills, Arellanes said, but after he appealed, it picked up 80 percent of most of the expenses.

Kelly, now 50, has gone through intense rehabilitation and needs tests and checkups every few months. Without her salary and battered by the bills from the emergency room and continuing medical costs, the family burned through their savings, retirement accounts, investments and their daughter’s college fund. With medical debts of more than $100,000, they filed for bankruptcy in 2005.

AT&T and United Healthcare would not comment on Kelly Arellanes’ case because her family did not give permission to make her medical file public for comment. Her current plan through AT&T has different rates of emergency care coverage, depending on whether the hospital is in network. Under the new law, that will no longer be allowed.

Reluctant To Seek Care The inclusion of coverage guarantees for emergency care in the new law “was a major victory for us,” said Angela Gardner, president of the American College of Emergency Physicians. “People often can’t stop to check to see if a particular hospital or doctor is in- or out-of-network when they are having an emergency,” she said.

Research suggests concerns about costs can keep people from going to the emergency room. A recent study in the Journal of the American Medical Association found that insured patients without financial concerns were more likely to seek emergency care within two hours, but almost half of uninsured patients or patients with financial concerns waited six hours or more to seek care.

A spokeswoman for the insurance industry, however, said problems with emergency coverage are not widespread and the law’s provisions generally follow what insurers already offer in their own plans. “I do not think this represents a major change for our members,” said Susan Pisano, a spokeswoman for America’s Health Insurance Plans. “It is already the standard most places now, if not universally,” she said.

Consumer groups disagree. Cheryl Fish-Tarcham, deputy director of health policy at Families USA, a nonprofit consumer health advocacy group, said that since some states don’t have regulations on the issue, the federal law will set a uniform standard.

Yet, even when states do have such laws, there have been consumer complaints about insurance company practices. For instance, last December, Pennsylvania insurance officials, working with the state attorney general, determined that 631 consumers had their emergency claims improperly denied between 2001 and 2007 by HealthAmerica, a Pennsylvania-based insurer. The company settled with state officials, admitting no wrongdoing but agreeing to reprocess the claims.

“The federal law gives us more teeth to enforce what we already thought was the right thing to do,” said Dan Honey, Arkansas’s deputy insurance commissioner.

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State insurance regulators – swamped by about the new health law – are looking forward to one of the earliest concrete pieces of the health overhaul: a consumer-friendly tool on the Web.

By July 1, the Department of Health and Human Services will set up a website that has a section for each state. Consumers and small businesses can consult it when shopping for insurance plans.

The federal website will have every health plan listed that is authorized by each state, a list of the plans’ network of providers, the services they offer, who is eligible and how to sign up. The portal will include private plans, Medicare, Medicaid, the and the new . It’s considered the first step in what will eventually be the state-based insurance exchanges.

The July 1 deadline for the preliminary Web portal was set in the health care law. With that date fast approaching, HHS recently on how to meet it.

Now the states are scrambling to get ready. “It’s going to be a lot of data entry,” said Stephanie Marquis, spokesperson for the .

The law spells out a pretty tall order for this portal, but HHS plans to roll it out , so at first it will just outline the basic plan information. But, come fall, more information should be available. “The goal is that by October, you can actually compare multiple plans,” said Marquis. “There will be specific links and explanations of what the benefits are and what your rights are.”

The portal is one of the parts in the health bill that’s supposed to help protect consumers, by making information clearer and more accessible – something most health plans usually aren’t.

But in the meantime, insurance departments like Washington’s are fielding “a lot of questions from consumers” and answering them one at a time, Marquis said.

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State regulators are cracking downÌýon a health care product that targets the growing group of uninsured and underinsured Americans: the discount health plan.

In discount health plans, consumers pay either a monthly or annual fee to get access to a network that is supposed to offer reduced charges for doctor visits, prescription medication and other medical services, such as eye glasses.

Unlike traditional insurance, consumers in a discount plan pay all medical costs up front, minus whatever discount has been negotiated with the plan. The companies often advertise networks that number hundreds of doctors and savings of 10 to 60 percent. To get the discount, patients have to use providers honoring the plan.

But advocacy groups say consumers are frequently confused because the discount health plans blur the distinctions between their benefits traditional insurance plan coverage.

In addition, some of the discount plans are not legitimate, consumer advocacy groups say. They don’t meet all their advertising promises and their networks turn out to be hollow lists with few providers.

“Oftentimes these are just schemes to commit fraud,” Kansas Insurance Commissioner Sandy Praeger said. Sometimes consumers think they are buying a traditional insurance plan, only to receive a discount card in the mail, according to Praeger.

Unemployed, Uninsured and Out of Options

Authorities in California began taking action against some of these unscrupulous companies. Linda Andlovec, 60,Ìýwas one of the customers who told her story to the state about her interaction with a discount health plan. In February 2009, the office worker got a phone call from . A few days before, her employer — a small business in Foresthill, Calif. — had announced it would be dropping employee health care coverage to try to cut costs in the recession.

The Easy Life salesperson was offering a special deal, Andlovec recalled: For $96 a month, the workers in Andlovec’s office could join a health plan with benefits that included free prescription drugs. If Andlovec didn’t like it, she could cancel and get her money back. The salesperson said the Arizona company also had agreements with thousands of California doctors in their network.

“I was scared but I was kind of frantic,” said Andlovec, who has high blood pressure and used at least three prescription medications regularly. So she used her debit card to pay $100 for the membership fee and $96 for the first month.

But as Andlovec soon found out, she was buying a discount health plan, not a traditional health insurance policy. She called to cancel as soon as she realized that the Easy Life plan would not cover her doctors’ appointments, medical treatments or drug expenses. Even so, she lost her $100 membership fee and didn’t receive a refund on the rest until June of last year. When her company went bankrupt last September, she was left unemployed, uninsured and out of options.

For years, discount health plans fell into a dead-zone of regulation. Since they aren’t insurance, they generally couldn’t be regulated by insurance commissioners. In the past few years, though, consumer complaints have forced state officials to take notice and begin to make regulation possible.

“The problem is that oversight is so spotty and often barely existing, that the marketplace has become a kind of Wild-West frontier,” said James Quiggle, spokesperson for the , a Washington, D.C.-based watchdog group.

Bad Economy Created Market

California has been among those states to step-up regulation after repeated complaints like Andlovec’s. The state’s , the first of its kind in the country, has taken the reins of regulating the discount plans because the insurance commissioner could not.

DMHC Director Cindy Ehnes said her department in February ordered Easy Life and its parent company, , to stop operations in the state. The DMHC said that the company was operating illegally in the state without a license, as well as misleading California customers and misrepresenting the products they were selling as health insurance instead of a discount card. The lawyer representing Healthcare One, LLC, Craig Zimmerman, had no comment about Easy Life’s operations in California.

Ehnes’ department has received more than 1,000 complaints about discount health plans since beginning an investigation of the products in 2004 and has ordered 18 discount health plan companies to cease operations in the state or get licensed. Downturns in the economy and rising insurance premiums have caused many consumers to lose or give up their traditional health coverage, creating a market in the state, she said.

“Many more Californians have been looking for a way to afford medical care and these plans offer themselves as solutions,” Ehnes said. But, she added, the state’s investigation of plans selling in California found that “many, if not most, were offering benefits that were deceptive and misleading.” Just five discount plans have been licensed in the state, only one of which offers medical services. The other four plans are all dental providers. To be licensed, the provider networks and discounts offered by the company must be verifiable and all fees must be refundable minus a registration fee of $15 maximum, among other requirements.

In Minnesota, the state attorney general several discount plans for deceptive marketing. Other states, such as Oklahoma and Kansas, have established legislation that allows their insurance commissioners to regulate the plans.

Yet officials seeking to crack down on misleading practices face some of the same confusion that many consumers do, especially when trying to figure out who is running a company. For example, the company that called Andlovec and her co-workers, Easy Life Healthcare, is just one part of Healthcare One, LLC. And according to the Texas Department of Licensing and Regulation, Healthcare One is a private label marketer that sells the plans provided by another company, . of Dallas. The fine print of the Healthcare One website lists the “administrator” of its product as Careington International.

Zimmerman had no comment on the relationship between the two companies. Calls to Careington International were not returned.

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Under the federal COBRA law, workers can stay on their former employers’ health insurance plans for 18 months after losing a job, but they must pay the full amount of their premium. However, as part of efforts to avert some of the effects of the recession, and as part of the stimulus package, Congress voted Ìý65 percent of those costs for laid-off workers. Here’s a brief timeline of the provisions:

* February 2009: Workers laid off from September 2008 — December 31, 2009 are eligible for nine months of the subsidies.

* December 2009: Eligibility is expanded to those laid off through February 2010 and the subsidy is extended to 15 months.

* March 2, 2010: TheÌýeligibility period for newly laid-off workers is extended through the end of the month.

The bill lawmakers are considering now is a short-term extension and is meant to buy Congress more time, again, to pass longer-term benefit extensions.

According to Judy Conti, federal advocacy coordinator for the , the billÌýoffers retroactive benefits to those people laid off between April 1 and when the bill passes.

Also, Conti said, the legislation would guarantee that people who enroll for the subsidy by the end of April will get the entire 15 months of federally subsidized health premiums, regardless of whether Congress passes another long-term extension to COBRA by the end of the month.

The longer-term options being considered include a Senate bill that would extend the subsidy through the end of the year. A House bill also offers a longer extension but the two bills would have to be reconciled.

While the debate continues between Republicans who say continually extending benefits without paying for it needs to stop and Democrats who equate unemployment benefits to natural disaster spending, one lawmaker wants to open coverage to even more people.

California Democratic Sen. Barbara Boxer introduced the “” on March 25 that would guarantee COBRA coverage for domestic partners, same-sex spouses and extended family members, not just spouses and children, as the law currently stands. The bill has been referred to the Senate’s Health Education Labor and Pensions Committee, but no word yet on if, or when, it will move from there.

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To ease the worries of already-strained primary care doctors, the new health law includes an increase in Medicaid payment rates, bringing them up to the same level as those from Medicare. That bump is is expected to be pretty helpful when a huge chunk of the increase in insurance coverage under the law comes from , the federal-state program for low-income Americans, to cover 16 million more people, including people with incomes up to 133 percent of the federal poverty line, or about $14,404 for an individual and $29,326.50 for a family of four. The expansion will include childless adults, most of whom were not previously eligible.

The problem? Under the new law, the Medicaid raise may only last two years.

Currently,Ìýprimary care doctors in Florida who treat a patient on Medicaid would have a hard time making money on the service. In fact, they’re getting paid about half what they do for Medicare patients. “My overhead is 60 percent. If I see a Medicaid patient, that’s like I am taking a $10 bill out of my wallet and handing it to them to see them,” said Dennis Saver, a family practice doctor in the Sunshine State.

Saver expects to make some profit under the new law on the 50 Medicaid patients he sees regularly in his private practice. He says the increase won’t make treating them “handsomely profitable,” but “it would make it reasonable.”

The higher Medicaid payments would take effect in 2013 and would be funded entirely by the federal government. But the what happens after 2014.

Some primary care doctors have voiced concerns about the law. But , president of the American Association of Family Physicians, says that while the law doesn’t solve every problem, it is a step in the right direction. “For folks that right now are getting charity care — if they become eligible for Medicaid then at least the doctor will then be receiving something instead of nothing,” she said.

In states like Texas, for example, where doctors currently receive about to treat a Medicaid patient than a Medicare patient, a jump in payment by one-third would be a big deal, says Stephen Zuckerman, a health economist at the . “It would be hard to visualize if that happens and providers begin to accept Medicaid patients that you’re going to then see in 2015 a 33% cut in those fees — but that is clearly what would happen if you read the legislation literally.”

Permanently raising the pay rate could help solve another looming problem: the .

Some doctors are also concerned that the increased reimbursements will be offered just to primary care doctors–and not specialists. “Even if you pay me more, that doesn’t build the network I need,” said Marc Siegel a practicing internist in New York who recently wrote an . Siegel also says a payment increase might not even cover the cost of doing all the paperwork that comes along with Medicaid reimbursements. “Let’s say I’m getting paid $30 now taking care of a Medicaid patient, maybe later I’ll get $45, but I’ll do 1.5 hours more administrative tasks, is that worth it?”

Nonetheless, experts like Zuckerman are boosting the effort, noting that the expansion of Medicaid has the opportunity to change the whole stigma of government-funded insurance. “As Medicaid eligibility moves up, you’re going to find broader geographic distribution of Medicaid patients, which will lead to shifts in the type of providers that Medicaid patients go to I definitely feel that it’s a movement in the direction of getting Medicaid to become a more mainstream part of the health care system,” he said.

But the payment increase could still end in 2014, which is why Heim and the AAFP are already working toward an extension to avoid another situation like the never-ending Medicare payment doc fix.

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The short answer is no. The Congressional Budget Office the overhaul law, as it expected to be amended by House fixes, would eventually cover 32 million more Americans. But that would leave 23 million that would still be uninsured by 2019. So maybe it’s not universal coverage? But who gets left out?

First of all, one-third of the uninsured group, or about 7 million people, are undocumented immigrants who are explicitly excluded. The other 16 million or so aren’t officially accounted for anywhere, but experts have a pretty good idea of who they are.

“Some people will be exempt from the mandate to purchase coverage because they will be unable to find affordable coverage,” Jennifer Tolbert, the principle policy analyst at the , told us. (KHN is a program of the Kaiser Family Foundation.)

That includes a large group of people of limited means who would be exempt from the individual mandate to get insurance. These folks wouldn’t have to pay a penalty for going without insurance if the cheapest available plan would chew up more than 8 percent of their income. People whose income falls below the threshold for filing a tax return with the IRS also get a pass. The problem is that some of these people might earn too much to qualify for Medicaid.

Even among those eligible for Medicaid, not everyone enrolls. “Compliance is never 100 percent,” , an expert on the uninsured from the Brookings Institute, told Shots. Some of them just don’t enroll, because they don’t know it’s available or don’t find it necessary.

Others who are exempt are those who have religious objections, American Indians, or those in between coverage for less than three months, but these categories aren’t estimated to include too many folks overall.

Also some people will remain uninsured simply because they and would rather pay the penalties instead, such as young healthy people. “On the average, insurance will be a good deal for the great majority of people, but that won’t be universal,” Aaron said.

But the ranks of those who opt out will thin as time goes on and the penalties increase, he said. The $95 annual penalty in 2014 probably won’t deter too many of those folks who don’t want to buy insurance, but by 2019 when it’s $695 (or 2.5 percent of a person’s income, whichever is greater), more people might decide to buy coverage.

For a sample view of how universal coverage can get ever closer without quite reaching the finish line, take a look at Massachusetts, which in 2006 enacted a law requiring state residents to have health coverage. Even there, 3.5 percent of non-elderly adults are still uninsured, a tiny number compared to the 15 percent national rate now, but not too far off the 5 percent expected by 2019. Just as the CBO projects for the rest of the country, the Bay State reports trouble when it comes to insuring young people and those with incomes under 300 percent of the poverty line, according to the of 2009.

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It’s already tough to find a primary care doctor in many parts of the country.

Look no further than Massachusetts, where insurance coverage is as close to universal as any place in the U.S., for a hint of the potential for trouble. Less than half of internists in the state (44 percent) are accepting new patients, according to data collected by the Massachusetts Medical Society last year. And the average wait time for new patients to get an appointment? Forty-four days.

An annual event that foretells the future specialties of new doctors shows there’s no quick fix coming. Last Thursday was “match day,” when seniors at American medical schools got matched with residency slots around the country. Lucrative specialties, such as radiology and dermatology, have been in high demand for years. Primary care, not so much.

The National Resident Matching Program touted the rise this year in students matched to family care programs. But others noted that the increase — 9 percentage points – still leaves a lot of growing room, especially considering the number of patients expected to seek new care because of reform.

Of 2,608 primary care training slots available — 73 more than last year — fewer than half were filled by American med school seniors. “This won’t make up for the shortfall, and there is definitely a shortfall in family medicine,” said Dr. Lori Heim, president of the American Academy of Family Physicians.

Even so, she remains optimistic, “We have a start, now we need to build on it.” Heim says the uptick might be due to all the talk about health care reform recently, from the media to lawmakers, and even President Obama. “The debate has really highlighted family medicine and primary care, and demonstrated that people value that relationship between doctors and the community, and what primary care brings to the health care system,” she told us.

And, she says, parts of the legislation don’t hurt either. The increase in student loans and loan forgiveness could help sway students who have been put off in recent years from primary care because of the much lower salaries those doctors receive compared with specialists and surgeons.

How much ground do primary care recruits need to make up? A lot. While U.S. seniors filled only 45 percent of the available primary care spots this year, specialties that pay much better had a 90 percent fill-rate by Americans.

The bill that the House passed Sunday includes a 10 percent payment bonus for primary care doctors, but Heim says that’s “nowhere near what we need to do to decrease a payment disparity of two- to three-times less” for primary care docs.

Still leaders in the field say they hope the increased numbers this year are the beginning of a turnaround. “This is a small number and in and of itself will not make much of a difference,” said Ed Salsberg, of the Association of American Medical Colleges. “We don’t know yet, but hopefully this is the beginning of a long-term trend upwards.”

This is one of KHN’s “Short Takes” – brief items in the news. For the latest news from KHN, check out our News Section.

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