Much of the debate about health care reform in recent weeks has focused on a just a few elements of the entire reform proposal - things like the public option and end of life counseling. But the proposed legislation is complex and wide-ranging, and the national fixation with just a few proposals is coming at the expense of meaningful discussion on other reforms which could have significant impacts on the state of health care. Here are five other changes reformers are trying to implement that we think are worth talking about:

1. The health insurance exchange: The proposed exchange is the mechanism through which many currently uninsured or underinsured people will be able to access health coverage. Individuals will use the exchange (likely a kind of web portal similar to the Massachusetts Connector) to shop for plans that suit their needs. Private insurers will offer plans that conform to the exchange's rules, so they won't be able to deny coverage or price a plan based on individual risk. A public plan would be offered through the exchange, but it isn't a critical component of it. There's no public plan in the Massachusett's Connector, but the existence of an exchange has still fundamentally altered access to health care in that state.

2. Medicaid expansion: The House bill expands Medicaid eligibility to 133.5% of the national poverty level, which will potentially making another 17 million people eligible for Medicaid. 

3. Caps on out of pocket spending: This is one of several consumer protections that health reform would enforce. The House bill outlines a minimum services package, which includes hospitalization, emergency services, preventive services, prescription drugs and maternity care. Insurers would be prohibited from cost-sharing for preventive care, and out-of-pocket payments for the other services in the minimum package would be limited to $5,000 for an individual and $10,000 for a family. This change is significant, considering that around 60% of bankruptcies in 2007 were related to medical expenses.

4. Health system modernization: A study by the Commonwealth Fund found that more Americans report medical errors than citizens of six other developed nations, including Germany, France, Australia and the U.K. The House bill recommends the establishment of standards for electronic health record keeping, which aim to minimize errors and monitor patient history.

5. Requiring insurers who participate in the exchange spend more of their premium revenue on patient care: The House Bill requires that insurers who want to offer plans in the exchange have a medical loss ratio (which means the amount of their revenues actually spend on providing health services) of at least 85 percent, meaning they can only spend 15 percent of premiums on non-health related expenses. (Now, insurers routinely fall below that ratio.) The House Bill would require insurers in the exchange to provide some form of rebate if they don't reach the 85 percent threshold. 

** UPDATE** I've received several emails asking why medical liability insurance reform isn't on this list. That's because this is a list of things that are in the bill currently before the House. Tort reform is not in the bill at present, although I expect it will be debated when the bill makes it to the House floor.

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