Published 3:45 p.m. Fri., 03.19.10 -The largest percentage of Missourians with health insurance, either employer-provided or individually bought, lives in Republican Rep. Todd Akin's second congressional district in west St. Louis County.

No surprise there.

But look again: The district also has many seniors hurt by Medicare Part D's so-called doughnut hole, meaning they must pay the full cost of their prescription drugs. This issue affects 12,500 elderly in the district represented by Akin (left) and a similar number in Republican Rep. Roy Blunt's 7th District in southwest Missouri. They rank at the top in that category for Missouri.

A second surprise: More uncompensated care is provided in Akin's relatively wealthy district than in Democratic Rep. Lacy Clay's 1st District, which takes in St. Louis and part of north St. Louis County.

These numbers, from a congressional study released Thursday, show that answers to who has health insurance, who gets the best care, and how much is spent in uncompensated care aren't as obvious as they might seem.

These issues were brought into sharp focus by a study by the House Committee on Energy and Commerce. It was released as the debate over the Democrats' health-care reform bill moves to a climax.

The highly controversial legislation, consistently attacked by Republicans and slated to be voted on in the House as early as Sunday, would cover 32 million uninsured and is projected to cost $940 billion.

That cost, the report says, would be covered several ways:

• eliminating waste and fraud in Medicare and Medicaid and reining in what it calls excessive profits by private insurers;
• increasing the Medicare tax for individuals earning more than $200,000 and couples earning more than $250,000;
• imposing a fee on the sale of some high-cost health insurance plans - the so-called Cadillac plans;
• taxing indoor tanning services.

The report also argues that the legislation would cut the deficit by $138 billion over a decade and by at least $1.2 trillion in two decades. Throughout the debate, Republicans have taken issue with the Democrats' numbers, arguing that the legislation is more likely to increase the deficit rather than reduce it.

Missouri has a lot at stake in this debate

According to the report,

• more than 404,000 Missourians lack health insurance, and nearly 12,000 have been pushed into bankruptcies because of health-care issues. Those numbers are said to be conservative;
• an estimated 95,000 Missourians don't receive full benefits due to pre-existing conditions, such as cancer, heart disease, and diabetes;
• roughly 97,000 seniors are affected by the so-called doughnut hole in Medicare Part D benefits for prescription drugs;
• inadequate health insurance translates into $850 million annually in uncompensated care in Missouri.

The 1st district, represented by Clay (right) Blunt's district, and the 8th District in southeast Missouri, represented by GOP Rep. Jo Ann Emerson, would seem to gain the most from the health bill. Together, residents of these three districts account for close to 190,000 of the estimated 404,000 people lacking health insurance in Missouri. For a more complete breakdown of statistics by district, see the chart at the end of the story.

Akin's district had the largest number of residents with private health insurance and the lowest number of uninsured -- 5,500.

The most interesting findings, though, involve uncompensated care. For example, more is spent on uncompensated care in Akin's district than in Clay's. One possible explanation: a trend among some poor urban residents to seek care in suburban hospitals. Many uninsured or underinsured city residents are said to prefer care in suburban facilities, such as St. John's Mercy, because they don't like the wait or the treatment in some urban hospitals.

Carnahan's district, if the report's numbers are accurate, provides three times more uncompensated care than Clay's and Akin's districts combined. A spokeswoman for the House Committee and Energy and Commerce said the numbers might be due to Carnahan's having a large medical installation -- the VA Hospital Center at Jefferson Barracks, which provides a lot of uncompensated care. In addition, she said, the numbers could be affected by large numbers of elderly residents in the district.

The spokewoman promised to check further, but said the panel stood by its numbers.

The communications director for Carnahan (left), Sara Howard, said his office agreed with the possible explanations about uncompensated care.

GOP leaders probably will find plenty to contest in this study, but it does seem to demonstrate that the crisis in health care cuts across party lines and, in some instances, is hurting people in middle-class districts as much as those in poor ones.

Details of the health-care proposal

In addition to providing snapshots of the state of health care by congressional districts nationwide, the House committee report highlights key parts of the Obama administration's health proposal. Click here to read the full text.

Among other things, the Democrats' bill would allow the middle class to keep its existing insurance and would would offer tax credits to families of four earning up to $88,000 to offset the cost of insurance. Out-of-pocket expenses would be capped at $6,200 for individuals and $12,400 for families as protection against health care-related bankruptcies.

Following is the committee's summary of some key provisions and when they take effect:

Immediately upon enactment of the law, the bill would:

• Offer tax credits of up to 35 percent of premiums to firms offering health insurance. Beginning in 2014, the tax credits will cover 50 percent of premiums.
• Provide a $250 rebate to Medicare beneficiaries who hit the doughnut hole this year. Beginning in 2011, the plan will offer a 50 percent discount on brandname drugs to seniors caught in the doughnut hole; it completely closes the hole by 2020.
• Increase funding for community health centers to allow for a doubling of patients over the next five years.
• Invest in training programs to increase the number of primary care doctors, nurses, and public-health professionals.
• Provide aid to states in establishing offices of health insurance consumer assistance in order to help individuals with the filing of complaints and appeals.

Ninety days after enacted, the bill would:

• Create a temporary reinsurance program (until insurance exchanges are available) to help offset the costs for employers that provide health benefits for retirees between 55 and 64.
• Provide immediate access to insurance for Americans uninsured because of a preexisting condition through a temporary highrisk pool.

Six months after enactment, the bill would:

• Ban practice of dropping of insurance when people get sick and have large claims.
• Prohibit denying coverage to children with pre-existing conditions. Beginning in 2014, this provision will apply to all people.
• Prohibit lifetime caps on coverage.
• Allow young people to remain on their parents' insurance policy until they are 26.
• Prohibit eligibility rules for health-care coverage that discriminate in favor of higher wage employees.
• Require new plans to cover preventive services with no copayments and exempting preventive services from deductibles. Beginning in 2018, this requirement applies to all plans.
• Require new plans to have an internal and external process for consumers to appeal decisions.

Starting Jan. 1, 2011, the bill would:

• Create long-term care insurance financed by voluntary payroll deductions to help adults who become functionally disabled.
• Require plans in the individual and small group market to spend 80 percent of premiums on medical services; plans in the large group market must spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders.
• Eliminate copayments for preventive services and exempt preventive services from deductibles under the Medicare program.

Many other provisions don't begin to take effect until 2014.