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The analysis below only highlights the negative aspects of this bill, but those are the aspects that are not being publicly discussed. Love it, hate it, look it up, analyze it or research it for yourself, and decide for yourself, what to do about this. I’m just suggesting "Eyes Wide Open".
When the term "public option" has become so general or amorphous that it can be read to mean anything that anyone wants it to mean, it is not only useless, it can be dangerous.
HR3200/HELP Committee Bill (which seems to be what is going to be pushed even by "progressives" in the senate) has lots of goodies in it that no one is talking about.
It features :
…An insurance exchange as the main "solution" for a "public option". An insurance exchange is private insurance companies getting together to offer a selection of policies obtainable through the government (with the government setting some standards of cost and who they have to cover). Under this format the government analyzes your finances and determines what you will pay per month, then gives you a choice of private insurance policies to choose from depending on what "tier" of coverage you qualify for. The money you pay goes directly to the private insurance companies and the rest of what the private insurer charges for that policy is paid to them by the government (if you qualify for an insurance subsidy).
…Subsidies for the exchange, paid to the insurance companies, which means everyone will be paying Big Insurance twice.
…and/or Tax credits (meaning even though you can’t pay your bills now, you have to pay the insurance companies anyway and maybe you’ll get money back later on your already too-complicated-for-humans tax return, if you prove and report those payments properly).
…Mandatory enrollment for citizens.
…Penalties for people that don’t sign up because they can’t afford it or simply don’t want to enrich the insurance companies.
…No mandatory participation from healthcare providers.
…A pathetic provision for possible "state insurance" (co-ops!) in it (also being referred to as "public option"!) that is funded strictly by premiums paid into it by its participants in that state. Not only would a creature like that be far too weak to "keep private insurance honest" and would be too small to negotiate meaningful discounts. It is the equivalent of a small start-up homeowners insurance company trying to operate without the back up of the massive resources of a parent company nor any re-insurance to back it up in the case of massive claims. That homeowners insurance company, by law, would not be allowed to operate. This brilliant idea is in both this bill and the "bi-partisan compromise" bill.
…And, of course, tiers! No plan would be complete without class distinctions.
Logistics of vetting 100+ million peoples’ finances to decide what they qualify for? Not a problem!
It’ll be the gift that keeps on giving!
This is the bill that is now being referred to as a "hybrid" (doesn’t that sound new, hip and eco-friendly!) because it has two! ways for the public to pay for coverage!
Using the words "public option" can now be construed as meaning any perverted definition of "public option" that suits the politicians. The term has come to mean anything that involves making coverage "available" to people that don’t have insurance.
By the way, BOTH senate bills (HR3200 & the "bi-partisan compromise" bill) include mandatory participation for citizens.
Yeah! Aetna’s up 12%.
Here’s a link to the summary: http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BILLSUMMARY-071409.pdf
The vast majority of what I’ve said (above) can be found here, you just have to read it and know what it is that you’re reading. The things that are in my description that are not in this summary, I’ve found from reading analysis of individual components of this 1000+ page bill.
The key to understanding this bill is to educate yourself to understand what an insurance exchange is and how it actually works in general, and with credits/subsidies, and also what a co-op actually is and how it works, so that you can recognize it when it’s being called something else.
Incidentally, you can find near the beginning, that the possible "state insurance"/"public option" (aka state co-op) may only be offered in "areas of the country" (meaning states, since it is state public insurance) where only a couple private insurance companies hold a monopoly; making this "public option"/co-op component even weaker than anyone has imagined. And why, after this wonderful insurance exchange is being offered, would a couple private insurers still have a monopoly in some states, creating the additional need for a "state insurance"/"public option" co-op, you might ask? Because there is no mandatory provider participation. Which means that in some places, even with an exchange, there might still be monopolies. If you notice, the summary also talks about the option of individual state insurance exchanges also, versus a national exchange.
Why do I say it’s mandatory participation for citizens? Well, if you don’t sign up for insurance (public, private, exchange, whatever) because you can’t afford it or you simply refuse to enrich the insurance companies or you just want to be left alone, there is a penalty. That would make it mandatory. And how would they know that you didn’t sign up so that they can enforce a penalty? Because you wouldn’t be able to show proof on your income tax. This, of course, further complicates tax returns but is the only way to ensure everyone in America pays the insurance companies that will be providing insurance through the insurance exchanges.
So…. the "bi-partisan compromise" bill from the senate finance committee has co-ops.
….And the "hybrid" HR3200 bill from the HELP committee has a component for possible "state insurance", which is co-op being called "state insurance".
Now, this is just conjecture, but ever since it was confirmed that the "bi-partisan" bill has co-ops, the pols (including Barney Frank and Jay Rockefeller among many others) are now running around saying that co-ops are a bad idea to every camera they can find. (Who wouldn’t? They are a bad idea.) I’m guessing that when it comes time for these two bills to be "reconciled", the co-op language will be removed from both bills and all that will be left is the insurance exchange and mandatory citizen participation (which is also in both bills)…. And idiots all across America will rejoice because we "dodged the bullet of co-ops"! I think it’s a set-up that’s being well-orchestrated.
Cynical? Absolutely. Possible? Absolutely.
69 Comments
Progressives need to learn that when they push for something involving lots of money, the corporations and their lobbyists will always win.
Excellent diary, Tracie.
Yup.
Very well done!
This interpretation of the exchange has some points I was not aware of. I was under the impression that the government would act as insurer along side “private” insurance firms (pardon my language) in the nebulously defined (state? regional? national?) insurance exchange. Among said profiteering firms would be chosen a contractor (most likely Aetna) who would manage the government insurance component of the exchange.
You seem to be saying the exchange would consist entirely of private insurance firms receiving premiums with the government only serving as backstop. If I’m not mistaken, your talking here about credits that would supplement the cost to individuals or families in certain income brackets. That is apart from the public option insurance scheme which I’m not convinced you’ve described completely.
In any event, the point is well taken that the bills floating about are intended primarily to enrich insurance companies and that the co-op gambit is only cover for that fact.
Single-payer is an insurance model as well, but the payer would be the federal government. If the usual pattern were followed, a profiteering firm would be contracted to manage the single-payer insurance system. That would be unfortunate. Health care should not be a for-profit undertaking.
A much needed and timely analysis. I’ve been warning in a number of posts lately that the “public option” idea is so vague that it can mean anything and that people don’t understand it, and I’ve also argued that if Obama is going to produce a good bill he has to leave the public option and try to mobilize people around “Medicare for All.” The term “single-payer” should also be used minimally in discussions. People don’t understand it right off, and one has to explain that it’s like “Medicare for All” anyway.
Excellent post, Tracie. I postponed reading this thing but it looks like I’m gonna have to get off my ass.
Thanks.
I’ll also call attention to this reply I gave to Jane Hamsher in commenting on another thread:
I think your post supports my view that HR 3200 is NOT “good.”
This post is full of misinformation and confusion; it’s hard to know where to begin.
It confuses the various bills, confuses the Senate work with the House work, doesn’t seem to know the difference between the exchange, a public plan within the exchange, and a possible co-op within the exchange.
It disparages the idea of providing subsidies to help people pay for insurance and mistates the role of govermnent wrt those subsidies and the application of penalties. It doesn’t seem to understand shared risk pools. It invents a process for “vetting 100+ million people’s finances.” It mistates the nature of the individual mandate.
There are at least a half dozen mistatments in the paragraph on “an insurance exchange” alone.
I don’t expect everyone to be up to speed. This stuff is hard, the bills are complex, and there is a flurry of misinformation coming from the opponents of reform. But whatever this poster intended, this is not useful or accurate analysis.
Can any of the many proponents of the public option Health Care Exchanges on this site give an example of where they have been successfully used?
Jason?
There’s a valid reason why you weren’t aware of the poster’s points: many of them are wrong or confused.
The exchange is not the public option. The exchange doesn’t have “Private insurance companies getting together” because that would be illegal collusion. There is no proposal to have the government set the standard for their costs. The House Bill(s) and Senate HELP bill give you an additional option — the public option — to choose from, not just private insurance.
The poster continues to confuse the exchange (the place where you make choices) with the choices themselves (private plans or public plan), and so when the poster discusses the state issues, the discussion is hopelessly confused. The House/HELP bills envision one or more exchanges that would be set up by the feds but could be administered by the states if they show they can handle hit. That doesn’t tell you anything about the Public Option.
The Public Option does not depend on whether the feds or the states run the exchange. So you could have a state running its region’s exchange (with fed permission/oversight), within which one could purchase the PO which has national scope. And when you move to another state, you’d still have your national PO insurance whether or not your new state operated an exchange for its region or the exchange in that region was run by the feds.
Draw a box and call it the exchange. It’s a place to shop. Now put several options inside the box, some private and one public option. You pick between private insurance and the PO. That’s the framework of those bills.
The co-op concept has confused this, and the poster hasn’t sorted it out, which is undertandable because the media/DC discussion of the co-op hasn’t sorted it out. Is the co-op something that is available only in your state, but you have to drop it and join another co-op when you move to another state? We don’t know. Because it’s not clear that a co-op could function nationally, the House bill would allow co-ops only in addition to the PO, not in lieu of the PO.
Finally, there is no Senate Finance bill, even though the poster keeps referring to it. They haven’t come out with one. Instead, the gang of six have leaked what they want/don’t want to the media, and those leaks tell us those six Senators don’t want a PO but might accept some co-op proposal which they haven’t defined yet.
Speaking of misinformation and confusion, scarecrow writes:
HR676 (Medicare for All; single payer) is only 70 pages long. (The text; the FAQ).
So, unless “the bills” means “some bills” or, more precisely, “my bill(s) of choice,” that statement is not true.
The concept of an “exchange” as a place to go to choose between different options is not new; there are examples in other industries. There is a health insurance “exchange,” called the “Connector” in Massachusetts. Those without insurance or small businesses can shop for insurance there. The only options are all private/for profit; there is no PO.
Is it successful? Define success. Its supporters think it’s worked well, others disagree. Mass has both individual and employer mandates (with exemptions and subsidies), so Mass has been able to reduce the number of uninsured to the lowest in the country, but is that a function of the mandates (probably) or the existence of the exchange (doubtful). The exchange just facilitates choice. It does seem to reduce transaction/information costs, as one would expect.
By focusing the residual market, it may have some benefit in helping to pool risks, and then helps in the risk sharing allocation — moving money from plans with low risk patients to those who insure higher risk patience, which would tend to spread out costs, but I haven’t seen studies on that issue for the Connector.
But it’s unclear (I would say doubtful) that the “competition” within the exchange has significantly lowered premium prices below what they otherwise have been. Since the “competition” is limited to the private/for profit entrants (there is no PO in Mass) the price competition is limited to what one can achieve in a fairly concentrated market.
Well, you got me there. 70 pages is certainly shorter than 1000 pages, especially if you’re only trying to accomplish some things in the 70 page bill but trying to do a lot more things in the 1000 page bill.
There is no argument that the concept of SP is substantially simpler to grasp and explain than having to explain how to “reform” today’s hydra-headed system and get all the pieces right and working consistently. I honestly doubt it’s possible to do this well, which is why I suggested weaks ago that the reformers keep the SP model in front of them as a guide, even if they didn’t believe they could adopt it, so I’m not about to defend the current approach, let alone suggest it’s optimal.
The current system is an unworkable mess, and trying to “fix it” and keep it’s main features in place is a doubtful enterprise.
This is a good post, Tracie, way to bring out the salient features about it all . . . .
But, HR3200 is ONE bill, from one senate committee . . . . do we IGNORE it? No, only at our own peril.
Is it what we will end UP with?
Not yet!
It’s a long race, still, with many backdoor decisions yet to be made in Senate AND House.
So we pressure and pressure those who oppose our wishes (us, we, the 73%) and we support, support those who HONOR our wishes.
I’ve read the criticisms listed in this thread elsewhere, I’m aware of them . . . . I would think most progs are?
But it NEVER hurts to keep the info out here in the toobz, used for talking points, etc.
But HR3200 is NOT the only thing goin on, and it ain’t over yet . . . hang in there progs, keep the pressure on anyway you can . . . .
At the end of this fight, we either get what we want, or, I predict there will be mass unity and protest on THIS one. A sell out to the corporations and our feudal overlords on this by Obama will doom him, and he KNOWS it.
With enuff heat on Obama and all of Congress, we can reduce the watering down to be as negligible as possible, and maybe even have a good piece of legislation as a first step towards single payer of some sort for universal coverage that’s based on medicare/VA, and other govt run services.
We hope on.
I’ve liked all you’ve written on the subject to date, so thanks for THIS feedback . . . as I stated above, HR3200 is NOT the end all, at this point. There’s lots of fight left before we win/lose/compromise.
On we hope.
I’m not going to be forced by law to buy insurance from a “concept,” which is why I want to kick the tires on a real example of success. (Since the health insurance market works differently from other markets, as Kenneth Arrow teaches us, examples of other markets are not relevant.)
Is MA Connector your only example of a health exchange you would consider to be a success?
If not, is MA Connector your best example of a health exchange you would consider to be a success?
You seem to be under the impression that I think the Connector is a “success” — I didn’t say it was or wasn’t– and that I’m an advocate of that particular model. I’m not. You asked for an example; I gave you one and you can draw your own conclusions about it’s merits.
I’ve written before that there is a reason why Obama would call the hybrid approaches being considered “uniquely American” and that’s because no one has ever done exactly what’s being proposed or shown it can work. I understand conceptually how it could work, but it might work or not depending on how it’s designed/limited/ etc and lots of factors we can’t predict, let alone control.
This path to “reform” is clearly suboptimal, but it’s where we are and it confronts us with hard choices about how to confront that reality. If I saw a plausible scenario along a different/better path, I’d be for it. But I’m so disillusioned with what’s become of American governance that I wonder whether even obviously suboptimal paths/outcomes are feasible.
The country has become, in my view, essentially ungovernable — we have a weak, often unprincipled, almost leaderless “left” party; a nutty/insane right party that hates government and is increasingly undemocratic and violence-prone in opposition; a totally corrupt political system driven by too much money from deeply entrenched interests; and a lazy, irresponsible media.
And from that we’re to expect really good reforms that overturn established interests with trillions at stake?
And the worst part is, the merits of ideas have very little correlation to their political success. In fact, it may be that in such a corrupt system, the more merits there are to a proposal, the less likely it is to getting it through the political process. I think that’s what’s happened to health care, and it’s not just taking SP “off the table.” It’s also the unwillingness to challenge brand drugs/patents, bargain for drug prices (though the House EC Committee nodded in that direction), the denials about whether market theory has anything to offer in the health sector (as you note). The reform conversation is narrowly constrained, not just on the topic of SP.
Disappointing inteview with Lynn Woolsey on the Diane Rehm Show today; She said the progressives have already compromised: They wanted single payer, but have settled for a good (undefined, and she was pushed) pubic option (undefined, same reaction). Sheesh.
She did report that the compromise leading to the HR3200 passage in committee included $5B for those health cooperatives (which do not exist and there are no models for what they might be), while the (good, Lynn?) public option would receive $2B. Does that tell anyone here how small and weak the public option will be?
She also said the coops do NOT have to pay back the $5B, but the public option, whatever it is, has to repay the $2B.
Feeling sick yet?
Later, two health care reporters said the AMA decided to support Obama bcz $245B was being written in to offset payments cut back in an earlier bill. The support statement was their thank-note to Obama.
Note that the back payment is more than the public option is funded with….
OK–what to do? Anyone in Woolsey’s district must call her. Others, why not, if she’s considered a leader of the prog caucus?
This is, however, pretty sickening.
Addition: Earl Pomeroy, Blue Dog-ND was on and said, concerning abortion coverage, that he was interested in health care and wanted to move on.
A woman called up very irate that he did consider women’s reproductive health to be a part of their overall health. Ticked off voter.
Oh, no, Mr. Bill–not Romney Care!!!!
Correction: HR676 is 30 pages long in legislative format (double spaced, very wide margins). In normal formatting and without sponsor’s names I printed it out in 10 pages.
“The country has become, in my view, essentially ungovernable — we have a weak, often unprincipled, almost leaderless “left” party; a nutty/insane right party that hates government and is increasingly undemocratic and violence-prone in opposition; a totally corrupt political system driven by too much money from deeply entrenched interests; and a lazy, irresponsible media.”
That’s nicely succinct. Well put.,
WRT the media, I’d suggest they are not JUST lazy and irresponsible, but that they are the vassals of the corporate feudalists who own this ungovernable mess we’re in.
Again, thanks for all you do, I really appreciate your musings and the hard work you do to boil it all down for the rest of us . . . . be well! We need you! ;-)
Yep — $5 billion to get maybe 5 Blue Dog votes to get the bill out of E&C — that’s $1 billion/vote, and the Blue Dogs don’t even care about the co-op. It’s just leverage to use later. And the progressives got what in return? Jane’s right. The progressives won’t fight for you unless you kick them hard enough.
I shouldn’t take more than that number to explain what you want. But if you have to explain how you get from here to there, and all the transitional arrangements that have to be rewritten/unraveled, it takes more pages. The number of pages to describe SP is not the issue. It’s the difficulty of the transition that is, because we’re starting from a radically different system for those outside VA/Medicare.
That IS sickening . . . but it’s not over. I really think Obama has, thru LACK of forceful pressure FOR strong public option/competition against insurance companies, backed hisself into a really crappy corner in terms of OUR interests, and HIS!
If he PASSES watered down reform that’s a giveaway to private enterprises, a hue and cry and stink will arise across the land that will make the 60’s/70’s antiwar protests appear tame.
If he VETOES bad legislation, he’ll have OUR support, but will be torn asunder politically from the GOP, and the corporate feudalists. I’d like to think if he vetoes, we can help him stand for 2010 and Dems, and for 2012.
But there’s lots left to do, and a tanking economy with no jobs SOON might do him in long before the HC Reform Or Lack Of It does . . . . sigh.
BTW, thanks for the Woolsey report . . . bad as it seems . . .
You give Romney too much credit. After negotiating the bill to protect the industry and leave out any PO (or any other challenge to private/for-profit insurers), Romney reneged on part of the employer mandates — which would have meant that part of the revenues the state was counting on to pay for subsidies to low income would have to be replaced by state budget or by reducing the subsidies, hence leaving more people uninsured. I wasn’t following at the time, but IIRC Romney tried to veto that part but the Legislature overrode the veto?? I’ll have to check.
Even with the employer mandate/funding, the cost of the subsidies has strained Mass budget, so this year they’re trying to solve the “escalating cost” problem by reforming the payment system for providers. I.e., they want to replace “fee for service” with some other model and try to get that by the doctors and hospitals.
The federal bills seem to be trying to do both steps — insurance mandates plus cost reform — at once, but it would have been nice to have five more years of experience to judge whether this framework can work.
scarecrow:
Well, I was willing to accept a definition of success as you defined success. Tactics aside:
I’m also coming to the conclusion that the “many proponents of the public option Health Care Exchanges” (whether or not you’re among them) have no examples that they are willing to define as success. As you write above: “Uniquely American.”
That wouldn’t matter so much (or not any more than usual) if we were experimenting with a market for automobile tires or zucchini futures, but we’re experimenting with people’s health here, without their informed consent, and while systematically ignoring systemic “treatments” that work and can be shown to work. Very little good can come of that. (And so much for Krugman’s idea that it’s all so simple if only the “whiners” would stop with the obfuscation already. He’s not going to one of the people who are going to be experimented upon.)
As for ungovernable… I can’t find the post, but it contains an image from Barry Ritholz, picturing the bailouts as piles of blocks. On the right, things like World War II, the Marshall Plan, the Moon landings, and so forth. On the left, the bailouts (of 2008). Needless to say, the size of the pile of bailout blocks (all from 2008) far exceeds the pile on the right. (Yes, constant dollars.) Stein’s Law: “If something cannot go on forever, it will stop.” The story of how the tent city in Providence self-organized (”Association is the mother of science”) may have more direct relevance than many of us have imagined.
Anyhow, in a system that both of us believe is broken, I think the most likely outcome of this experimental “reform” will be a system where people (like me, and millions like me) are legally mandated to buy junk insurance that won’t cover us anyhow. That leaves us worse off, since paying nothing and getting nothing is better than being forced to pay something and still getting nothing. As Catherine Austin Fitts says: “Make a law, make a business!”; in this case, the junk insurance business, with policies that cost a little less than the penalty. (Maybe the PayDay Loan folks will be willing to sell them. On time…)
So, under such circumstances, I think it makes sense to demand justice rather than settle. Which is why I am advocating for Medicare for All as forcefully as I can.
Most or almost all of which would not need to be done with single payer.
Or is your argument that the complexity of HR3200 is primarily due to its careful consideration of transitioning?
So, in terms of lessons learned, why decide to kick the Blue Dogs instead of the Progressives?
More on MA compliance:
I’ve got to run, so I don’t have linky goodness, but my impression is that coverage was initially high, but after people actually had a year or so to taste the sausage, they decided the value of the plan was less than the penalty for not obeying the mandate, and so compliance began to drop. Don’t know what the recent figures are, but given the givens…
No, that’s not the point. There are whole chapters of the current bills that are not about insurance reform/competition, etc but about other ideas they want to do — such as support more education, incent more providers of a certain type, support more clinics of type x or at location y. These are separate from whether we should have SP or some exchange/PO hybrid.
Yes, I’d expect people to start making rational calculation about the cost of insurance, the value of benefits and the size of the penalty plus the cost of non-coverage. The incentives will drive outcomes, which is why I’d be nervous about Congress trying to set these in statute. They’re bound to get it wrong.
I appreciate the contributions of Scarecrow, both here and elsewhere, but there’s no arguing the public option bills under consideration are seriously flawed and favor for-profit insurance firms. The lack of leadership and determination on the part of the president is a major handicap to whatever progress that could be made on reform.
Lambertsrether, HR 676 appears to be 30 pages.
Thanks, Scarecrowe for this very clear statement.
Whenever I see a diary and comments such as these, I always wonder: for whom is the attacker speaking? Himself or herself? Or his or her proprietor.
I don’t mind being attacked.
Just want to know who’s behind the attack.
Sorry, Larue. I think your optimism about the President and what he knows is misplaced. I wish he did know that if he sells out on this one, he’s a one-term president. But I think he believes that his communication operation can spin any sell-out to the industry, and that if the economy has recovered by 2012 he will get a second term.
I also think the problem is always the alternative. I can’t see a Republican on the horizon who, if elected, would not be even worse than Barack Obama. So, unless we’re prepared to organize and build a third party in the face of all the barriers existing to hinder this, or unless we’re prepared to take over the Democratic Party over the next four years, we’ll still be faced with Obama or an even worse Republican in 2012.
Well, even I wouldn’t claim the following:
1000 – 30 = amount of cruft in HR3200.
However, we’re just using page count as a handy proxy for complexity (much as lines of code are a proxy for programming effort, or at least billing…)
So, when you’ve got:
1. Health Exchanges that have been untested except possibly in MA and never on a national scale;
2. The apparatus to compete with the insurance companies enough to keep them honest, but not so much as to drive them out of business (the firewalls and means testing and so forth)
It’s clear that there’s a considerable amount of cruft in HR3200 even after we take out the health clinics and the other good stuff — real complexity that remains, whose only real purpose is to guarantee the insurance companies a market. I think an order of magnitude of cruft would be fair: 30 vs 300.
Then again, reverting completely to snark, “Public option: Only one order of magnitude more crufty!” is hard to fit on a banner…
NOTE 30 not 70.
QUERY On the broader question: How are “rational calculations” to be made in an ungovernable society? Seriously… I’m sure a smart political economist has an answer to this — perhaps Thomas Hobbes?
You are right on.
Right on.
I’m going to say this again, because whenever I do say it, there’s never a response (and not even snark or abuse). Je répète:
Is there any [public option|HR3200|incrementalism] advocate who can reassure me on this? I’m perfectly willing to listen, if someone will speak on this point. What do I have to believe to be true for the above outcome not to come true?
I share the pessimism, disgust and rage over the possibility that the bills (aside from all the “good stuff” that’s desperately needed) will eventually just be a guaranteed inflated market for the insurance industry.
I’d choose single payer and I remember how simply Scarecrow has defined that (or was it a PO model) in the past. But I remember reading the the first 18 pages of one of the “bills” (I couldn’t go further because the screen went blank for some reason)and thinking there’s tons/billions of major bureaucracy built into the proposed system. I can appreciate that some of that will be essential, but while it may not be like the Clinton’s “jillion” boxes of yore, I shuddered at the comlexity of processes outlined; competing values battling to define the shape and content of the final procedures to be developed.
I’m angered over the proposed 2013 target, particularly in relation to the “public option”, whatever it may become. I work as a volunteer counselor for health care needs of folks grossly shut out of any meaningful health care. I know they are trying to deal with very complex health problems that most doctors do not understand, don’t know how to diagnose and treat. Some of these folks are homeless, some are on MediCal, Medicare, or grossly underinsured with their employer based or individually purchased plans.
This last week I saw my young and very extraordinary eye surgeon for a check up on a condition that will likely mean I will be really blind and not just legally blind at some point. Knowing about my health advocacy activites, for which he has been very supportive, we got to talking about health care reform issues and one particular patient I’d been helping, who had been totally screwed by Kaiser Permanente by their incompetence and business plan model for reducing health care costs.
Obama had been quoted in last week’s TIME mag saying he sees KP as a model for what’s needed and I wanted to scream in disgust and rage, because I’ve talked with too many patients about their endless frustrations with KP’s actions and inactions. My doctor said he knows KP has a lot of great doctors, BUT… their health care procedures and guidelines really are severely constrictive because of their cost savings goals.
Then he said he gets Obama’s emails from the WhiteHouse.gov site and noted that he’d gotten one that outlined the health care reform principles he was seeking for the reform bills, all of which he affirmed. But then he said, “while it would cover everyone and do much good, it would cost $15 trillion rather than the $1 (+/-)trillion of some of the legislative goals.” He said no one really knows how to do what’s needed;he fights with insurers and provider groups all the time over the inanities of their policies and procedures that are far more costly and cumbersome then they need to be. He longs for a way to make things right and if I have any answers, let him know.
I don’t have any answers on the macro level. And the answers I have at the micro level (i.e. for individual patients that I’ve been involved with over the last few years) I have no way to make it right and fair and just; so I stay in despair for them and myself. And I don’t even have cancer or other life threatening conditions. I do have a pretty good primary and easy access to needed specialists, but I know how limited they are, how limited the medical group and advantage plan (that is reasonably affordable on my small SS income) are in meeting my needs. God help the folks who don’t have any of the benefits I have.
The TIME article quotes Obama saying that he doesn’t understand, and is frustrated by the reality that while he so clearly sees the problem, short and long term consequences of the problems, and the frameworks for solving the problems, others do not see and understand and so are blocking passage of needed reform bills.
Did he say he’ll settle, just to get a bill, as some one above suggested. I think not, but I don’t know what he’ll do. One headline of an article seen this last week, God knows where, suggests that he’s pushing hard but promising less.
I’m enraged by the subterfuge of the Blue Dogs and the co-ops, etc. etc. My House Rep (Mike Thompson)is one of the Blue Dogs and thus certainly not a part of the progressives, but he is the one and only Blue Dog who sided with the progressives in the vote last week. I don’t have the details of exactly what that vote meant, but I was proud that he broke ranks. I need to go to his site and learn more of his position and goals and thank him for his vote. When I had called a few weeks ago I was told that my concerns would be communicated to him, but he wasn’t for single payer because he believes that the private insurers should have a role. I don’t know that really means and he may not either in terms of implications; does it mean that they’re essentially going to run the show entirely (with or without a “public option” no matter how “robust” it would be) and they’ll get all the money so that the bills end up being another totally unneeded “bail out” for the industry? Anyway, I owe him a thank you for breaking ranks. I doubt seriously that my call had anything to do with that decision, but I’m glad I made the call.
I continually give thanks for Scarecrow’s radical commitment to help us understand the issues with his cogent and lucid analysis from untold hours of research. I understand his reluctance to take a stand on what should be, just as I understand my doc’s inability to define what’s needed and how to get there in a way that is just. Although Scarecrow did promote Jane’s three issue campaign to reach the progressives at one point.
I don’t know whether we should, as someone above suggested, give up because the bills as proposed thus far are so bad, and seek to stop the process. Bernanke always says he had to hold his nose last fall/winter when he was arranging to bail out the bad guys. Do we hold our nose and say, OK anything, just anything, let’s just get something, because maybe some of the things we want will survive.
I understand and appreciate Scarecrow’s conclusion about the nation being ungovernable. What I don’t understand is that it does not leave him in despair as it does me. But I thank God that he is able to transcend the insanity and keep learning and sharing and hanging in, just as others who people these pages do most days.
Blessings,
Scarecrow,
I find your post confusing and full of misinformation.
I am only discussing one bill. The bill summary of which I have given the link to. The senate finance committee bill is only mentioned in passing.
Everything I am discussing is in this summary. Have YOU actually read it? Beginning to end? While paying attention?
Or perhaps you read it as slap-happily as you’ve read my piece.
I do not disparage poor people getting subsidies. I am disparaging the government giving tax-payer money to private insurance companies.
I didn’t invent the 100M+ people that will have to be processed. That is the number of uninsured plus all the people that carry only junk insurance that is virtually useless and would be trading in/up.
I absolutely do understand the difference between an exchange and a co-op. As for the public option? I suggest you read the summary carefully and you will see what is being called a public option. It’s pathetic.
Here is a link to the center on budget which discusses in depth how insurance exchanges work. http://www.centeronbudget.org/…..38;id=2785 I suggest this also be read carefully.
I am not an opponent of reform. I am an opponent of mandatorily giving everyone’s money to Big Insurance and naively expecting to be taken care of.
I am also an opponent of supporting anything that is not clearly defined, such as the amorphously used term “public option”.
Before you do more blustering at me, take a little bit and actually read the subjects of my analysis, so that you’ll be “up to speed”.
And “mistate” and “mistatements” have two “s”’s.
I think my “conjecture” sums up my beliefs on the outcome of this “reform”. I’m actually beginning to hope that the entire thing will blow up and the healthcare mess will continue to become so insanely horrific that congress will be forced to do true single-payer next time we approach this. All of the “Uniquely American Solutions” being offered at this point are nothing but a convoluted disaster at best and a mandated astronomical winfall to Big Insurance at worst. I don’t call that meaningful reform in any positive connotation.
Personally, I’m sick of hearing that we “have to realize we’re never going to get a perfect solution”. Why? WHY should we HAVE to accept that, when there is a perfect solution (and only 30 pages because it’s not convoluted) and and it has been proven in every industrialized country in the world. I don’t give a damn if it’s not “uniquely American”. In fact, the term “uniquely American” has come to have a REALLY negative connotation. The only thing standing in the way is our politicians and their owners.
WHERE are the single-payer commercials educating the masses? Why do we have to keep being told that we HAVE to accept what they give us, until we say it to ourselves, even?
Now there’s the jedi-mind-trick. To make us fatalistic and more accepting of whatever THEY decide we’re allowed to have and that we should be appreciative of whatever idiotic thing that is; because “at least we got something”. We’re much easier to deal with that way. We truly are a nation of sheeple.
The answer has little to do with being or not being a PO advocate.
The House bill would outlaw certain insurer practices that create many of the horror stories today. Denial based on prior conditions, denial just because you get sick, rescission for innocent mistakes, etc. The bill also repeals the limit an total insurer payout. The bill also provides subsidies for lower to middle income folks to purchase insurance. Those “benefits” are separate from whether there is a PO or not. So if the bill passed, in the future, you’ll have some financial assistance to help purchase insurance that has fewer bad features than insurance has today. I don’t know whether this is worthwhile to you.
In addition, if there is a PO, and eligibility is allowed to expand, it’s conceivable that it could put downward pressure on premiums. That’s the hope. If eligiblity remains too limited, or it’s not well managed, then it probably won’t be an effective competitor. But if the choice is whether to have the above insurance reforms without a PO or the above reforms with a PO that might reduce premiums from what they would otherwise be, I’d choose the latter with the PO.
I should also mention that when I called in to the Thom Hartman show on Friday to discuss this topic, he confirmed, re-iterated and added to all of the awful things that I have written about the insurance exchange, subsidies and everyone paying twice.
This is not just me seeing this.
The MA health deform sucks. The Connector plans are prohibitively expensive. I should know, I’m still uninsured, but now I also face a fine for being so. Premiums here have risen faster than the national average, so if that’s what you want, have at it! The insurance on the exchange is mostly high-deductible(unless you can afford the extremely expensive plans). We have a public plan with the same firewalls as Congress is talking about now, and no one in their right mind would pretend that is turning into single payer here. Indeed, there have been a number of cuts to peoples benefits and a number of people cut altogether from the public plan this year. Our leg is also cutting 120 million in subsidies. Also, since this was really just an “accessibility plan” anyway, ie make it law people have to be insured, you’ll improve your insured rate, policy makers are looking every other way to get to affordability, except expanding the state program, global payments, MORE high deductible plans through the exchange, annual enrollment rates so people can’t “game the system”, etc. This isn’t good health care reform and should never have been the basis for creating affordable health care for all Americans.
I’d like to understand which bill(s) you are discussing.
1. In the third paragraph, you refer to “HR3200/HELP Committee Bill.” Does that refer to the bill being summarized at the site for the House Committee on Education and Labor? This site:
http://edlabor.house.gov/blog/…..-act.shtml
2. When, further down in your post, you provide a link to a pdf document called AAHCA BILL SUMMARY, are you referring to the bolded link to America’s Affordable Health Care Act, Summary at that same Ed and Labor committee link?
3. When you refer to HR3200/HELP Committee, are you referring to the House Bill or is this also covering the Senate bill passed by the Health, Education, Labor and Pensions (HELP) Committee?
4. About half way down, you say, “By the way, BOTH senate bills (HR3200 & the “bipartisan compromise” bill) . . .” Which bills do you mean? Does this refer to (1) the Senate Bill passed by the Senate HELP Committee and (2) the proposals, still not passed, by the Senate Finance Committee?
5. When you refer to “A pathetic provision for possible “state insurance” (co-ops!) in it (also being referred to as “public option!)” that is funded . . .” to what are you referring, and in which bill?
That sounds like other stories I’ve heard and about what you’d expect if there is no meaningful competition or other efforts to reduce provider/insurer costs.
You refer to a public plan — I didn’t think there was one. What is that? Do you mean state contributions to Medicaid, or something else?
Yes, but it’s called MassHealth. It’s actually quite good if you can get it.
And, Masshealth is on the Exchange, if you make less than 400% above poverty it is one of your options(though they use a host of administrative techniques to keep the rolls lower). Otherwise, you are firewalled out.
Scarecrow:
First, in my experience as an outsider to the public option discussion, my experience has been that indeed the answers will differ, according to the person to whom they are posed. This is part of the human condition, it seems to me.
Second, I guess the question of whether I’ll be forced to buy junk insurance or not can be answered by weighing your lucid explanation of what should happen given HR3200 against what actually happened in MA. To be continued….
Can you look at One reading of HR3200’s Sec. 102 (”Protecting the Choice to Keep Current Coverage”) clause (b):
Y1 is 2013. Does this clause mean that, for existing employment-based health insurance plans, they don’t have to meet the essential benefit package requirement until 2018, and after that there’s a grace period?
In English — If you’ve got employer-based insurance, it’s status quo for 9+ more years? (I could be wrong, since I didn’t Easter Egg hunt any farther than Section 121, but that is this layman’s reading.
+1000-type questions.
As I understand what the House bill does, it sets the standards for what policies offered in the exchange must cover, and there would be different levels from which to choose. The idea is to try to standardize each level of coverage, so that when you’re shopping (at the exchange), you can compare on price for roughly comparable products. The Mass Connector version of an exchange doesn’t have public option, although it seems to require you go through the Connector to get access to Medicaid (per masslib, called MassHealth?). To the extend that the exchange thus starts bring different programs under one umbrella, it’s probably a good idea — with the logical extension being everyone is under that umbrella, as they would be under SP. I think that facilitates the effort to get broader risk allocation.
We can’t really know how this will work out until we know what the policies offer and how much they cost with whatever competition the PO provides, and how much the subsidies are. And then measure that against how much people can actually afford. One of the “cost-cutting” compromises the Blue Dogs extracted was to raise the level of individual contribution, (I think it was from 11% to 12%, or in that range). These small changes can be the difference between insurance being affordable or not, depending on your income, etc.
In a sane world, single payer would be the compromise, and a National Health Service the left position.
As it is, “public option” is the left position, and whatever’s left after the Senate guts it will be the compromise. You know those automatic insulin injectors they have, where you dial in a dosage and it does the rest? Maybe we should just go ahead and have automatic money OUTjector to the insurance companies. They make call, I dial them up a little more of the money they need so much. Less bureaucracy, much more simplicity…
Incidentallly, “bluster” is a bit over the top, to me. I’m seeing scarecrow trying to keep upright in pretty choppy waters.
On the MA precedent, I’m interested in finding out how two rational actors played their parts:
1. How (and not whether; making a profit is their fiduciary duty) the insurance companies gamed the system; there was probably at least one consulting firm to help them do exactly that; and
2. How (and not when) people decided compliance wasn’t worth it and took a hit on the mandate penalty.
A program of research that should be useful, given the huge experiment that’s about to be performed on me on the very slender empirical base of a single and not really comparable state program, and without my informed consent. (That’s not snark, by the way. That’s outrage.)
I think that’s right, and that’s pretty egregious. The only thing I’d add is that this applies to policies in effect on Day 1 — 2013 — and if an employer starts a new or different policy, then this grace period doesn’t apply.
What’s not mentioned is what happens to premiums in the interim? This doesn’t say they stay the same. I’d expect them to rise, and when they get to a certain point, the employer either shops around for another employment-based plan — and the section doesn’t apply — or the employer just gives up, drops coverage, pays the “pay” fee for “play or pay” and the employees become eligible for the exchange. Or, after 2015, eligibility for the exchange is expanded by the Sec. of HHS.
What all this tells me is that they’ve set up the “firewall” to prevent too many people moving too quickly to the exchange, because they don’t want to have to pay for the subsidies (or don’t want to do more than they have to that CBO will score as increasing the federal budget). As I’ve written a number of times, “it’s the economy, stupid,” not the portion of health care costs cycling through the budget. It would be fine with me if most of the costs got cycled through the budget (via SP), as long as the nation’s total health bill went down. But in the current debate, the focus is on the budget because we’ve got Pete Peterson’s Institute, the Republicans, the Blue Dogs, and the stupid Wa Po screaming about budget deficits and the entitlements problem (read, Social Security). The whole discussion is distorted and irrational.
I’m sure the insurance companies would be happy to arrange direct electronic payments from your checking account to theirs. All my creditors — cable, utilities, phone, etc are very happy to set that up for me, for my convenience, they say.
I love the amount of words spent here in the comments on a bill that can never pass the House, much less the Senate. Keep up the fight for single payer. You’re going to get a vote. See what happens.
This is kinda a bait and switch…HR 676 is 70 pages long because it hasn’t been put through markups in committees yet…if and when it does and amendments are added, it’ll balloon to hundreds of pages easily.
A few funny things happened on the way to clarifying my critique for you.
I disovered that:
a.)House HR3200 is called America’s Affordable Health Choices Act.
b.)The Senate HELP committee bill is called American Health Choices Act.
c.)These bills are often referred to interchangebly, not only because their names are nearly identical, but because in a side by side comparison they are virtually the same in every way that I have criticized. See comparison chart here: http://www.cahc.net/documents/…..ummary.pdf
So, basically everything I’ve said in my analysis of the summary of HR3200, which was the only bill summary I was analyzing (at: http://edlabor.house.gov/docum…..071409.pdf ) still stands because it also applies the the HELP Committee bill.
So, yes, you were correct in thinking I was mixing house and senate bills…but not in any meaningful way. Mostly, it seems, you were being purposely obtuse in order to sound superior. Because if you’re half the wonk that some of your fans think you are, you would have already known all this.
Nice use of the passive voice. Sorry, but the only person mixing up the Senate HELP bill and HR 3200 around these parts is you. And they are not virtually the same. The provisions in HR 3200 as voted out of the House E&L committee are considerably stronger than those in the Senate bill. The Energy and Commerce version, watered down by the Blue Dogs, brings it closer to the Senate HELP Committee bill.
Christ, Tracie, I’m on your side and I find your imprecision and stridency insufferable.
Is 11% of income for premiums alone affordable?
Do you think that’s a good idea? Who will have the incentive to buy the low premium/less coverage vs. the high premium/more coverage plan? This is not how you create equitable health care for all.
No, you can get MassHealth two ways. By applying, or by going through the Connector and finding you are eligible. I don’t see that as very distinct from the Exchange, as they are talking about firewalls in terms of income, which are the same firewalls in place for MassHealth, but maybe I’m missing something.
I believe the tone was set with post #7, but obviously I’m not accomplishing anything here. Suffer no more.
Have a nice evening.
Thanks for the clarification. To answer your earlier question, yes, I had read the summary when it originally came out.
I agree the Senate HELP bill shares a similar structure with the House bill, HR3200, so those shared concepts can be discussed even though there are differences in details that can matter on some issues. And neither bill is the same as the still vague proposals coming from the Senate Finance Committee.
I don’t claim to be a wonk, or even half a wonk.
My reaction to your post, which was, uh, not as polite as it should have been (my apologies), was to the possible confusion of terms like “exchange,” “public option,” and “co-op” and an additional term “state plan,” which I didn’t see mentioned in the summary you linked to. That’s what led me to think you might be discussing different bills, but it appears you were not.
Sorry. It’s 30 pages.
The Sac Bee’s Sunday Forum section’s lead article (almost two pages) carried the headline: Is it about healthcare, or about making money? The article was written by Micah Weinbert, a Senior Research Fellow in the California Program of the New America Foundation, purported to be a
The headline and writer intro really caught my eye, so I was hoping for some meaty discourse; what followed was meaningful, at least philosophically, and I could agree with his conclusions. He did not offer the kinds of even broad details of how we should structure delivery of real transformational health care reform legislation and his critique of the legislative process thus far was quite vague. Still he had some interesting things to say that I’d like to share with the FDL community, as some of his comments touch on some of the above debate.
He begins by defining the basic issue as being one of costs: what it will cost in terms of federal budget amounts vs. what individuals AND families will have to pay for whatever options they choose. These costs can move in different directions. Then he goes on to say:
Congress has worked to find ways to reduce the amount that both the government and American families spend on health care
He quotes Dr. Atul Gawande, a surgeon at a Harvard Medical School related hospital, saying that the battle is “for the soul of American medicine.” In any given medical care encounter, regardless of the presenting problem, the question becomes whether the doctor meets the needs of the patient first and foremost or to maximize revenue as they are pulled between moral vs. economic imperatives. Since they’re operating within a “fee for service” structure vs the preferred reform of providing only the right care at the right time, even if it means cutting into their bottom line.
He then offers examples of transformational models now being implemented in our area, and proposed in Massachusetts. The CEO of Catholic HealthCARE West in the Sacramento area insists that
CHC has joined with Hill Physicians and Blue Shield of California to create an integrated delivery system that aims to provide a lower cost, higher value option for some Sacramentno-area public employees.
In Mass, a broad group of health care stakeholders
(He does not explain what that means, but it might help with some of the problems in Mass that are discussed above.
Weinberg sees that the main goals of the fed legislation are to “provide coverage to everybody while also making the system perform better for patients. The more value we get for our medical spending the more generous the country can afford be in providing quality health care to all people.” The problem, however is that the currently proposed legislation are relatively timid when it comes to delivery system reforms…. While calling for pilot programs to experiment with bundled payment, he says there is no mechanism to scale these programs to a national level.
At the same time, he insists that substantial transformative health care reform is already going on within health care delivery systems across America and Congress needs to catch up.
Finally he urges us all to contact our representatives and insist that federal health care reform legislation be done right….. “Health care policy is too complex to be reduced to sets of ideological talking points; it is too important not to be right because the stakes are literally life and death”…..
So the message for me was that he didn’t have really specific answers; his general vision fits within Obama’s proposed framework and it’s up to us to keep on demanding just and real reform legislation, whether I (and maybe others) are in despair or not. Keep on keeping on. Doing the research, doing the analysis, staying in the FDL debate process, making calls, writing letters, sending emails, respond to Jane’s appeals, etc. etc. etc.
Blessings
Thank you, Scarecrow. I appreciate it. Incidentally, during all of this back and forth today, did you at any time go to the edlabor.house site? Specifically the link I gave? If you did, did you see the long preamble style statement done in two different type-faces at the beginning before it gets into the breakdown of sections?
Yes. I read those documents a couple weeks back when they were first posted, and checked the Summary you linked to again trying to understand your post.
But you did see the long preamble style statement done in two different type-faces? Correct?