Tuesday, December 08, 2009

Catching up: health care

Updated The Senate's health care deform bill keeps plugging along like "The Little Engine That Could," going "I think I can, I think I can." And it very likely will, because too many have too much invested in getting something passed to keep them from making whatever damn fool change or further surrender disguised as "compromise" will be necessary to do it and at some point the chant will change to "I thought I could, I thought I could." Except the result of climbing this particular mountain increasingly looks like a train wreck.

The more I hear about this bill, the more shortcomings and limitations is has, the more loopholes it contains, and the less I like it. As the Washington Post was good enough to point out just over a week ago,
[m]easured against the promises President Obama and congressional Democrats have made about health-care reform, the bill ... could be setting Americans up for disappointment: Some of the main reforms would not take place for several years, and even when they do, some observers say, the bill does too little to make sure they would be enforced.

Until 2014, insurance companies could continue to deny coverage or charge higher premiums based on people's medical history. Another highly touted reform - banning annual and lifetime limits on coverage - would take effect in 2010, but it would permit significant exceptions.
After all, the White House says, you can't expect insurers to take just anybody, not until after there's a national mandate to have insurance. That wouldn't be fair. And that mandate won't come - and neither will the subsidies to help people buy insurance - until after the "exchanges" are in place and that won't happen before 2014.

And limits? We don't need no stinking limits:
Where annual benefits are concerned, the Senate bill bans only "unreasonable" limits. What that means is not spelled out; a Senate aide said the Treasury Department would set the standard.

In addition, the bill says that certain health plans could continue to use annual and lifetime limits. As Timothy Stoltzfus Jost, a law professor at Washington and Lee University, interprets it, those potentially exempt from the ban include companies that self-insure, meaning they pay employee health benefits out of their own coffers, and businesses with more than 100 employees.

Further, the prohibition on lifetime and annual limits applies only to limits "on the dollar value of benefits."
That is a limitation insurers have evaded in the past, such as by putting limits on the number of visits for certain benefits rather than on the dollar amount of claims. In one example, regarding mental health coverage, the GAO informed Congress of the practice in 2000. It took another eight years for the loophole to be closed.

And don't count on an end to recissions, either. Canceling policies for reasons other than fraud or deliberate misrepresentation has been illegal since 1996. The Senate bill continues that same standard, allowing for recission in the event of "fraud or intentional misrepresentation of material fact" - which is exactly the set of claims the companies make and have been making for 12 years! What, you think they send letters saying "we're canceling your insurance because you got sick?" There's always some claim of withheld information or some such.

So you get canceled illegally, canceled even though you did nothing wrong, canceled supposedly because of a flu shot you forgot to mention but actually because you started to run up claims? Good luck having anything done:
[T]he federal agency responsible "has done nothing to enforce those rights or to ensure that states do so," Rep. Henry A. Waxman (D-Calif.) said in a hearing last year.

An official testifying for the agency, Abby L. Block, confirmed that it had taken no enforcement action. She said her hands were tied unless it appeared that a state was not "substantially enforcing" the federal requirements.

Despite the HIPAA standard, most states have allowed rescissions even if policyholders' misrepresentations were accidental, the staff of the House Energy and Commerce Committee reported this year.
Which means, ultimately, that the whole fricking bill is "toothless," in the words of Betty Ahrens of the Iowa Citizen Action Network, a sentiment echoed by Jost:
"Unless an administration is in place in 2014 that is deeply committed to pushing recalcitrant states aside and taking direct action, it is likely that the reforms may never be implemented adequately throughout the country," Jost wrote in a recent blog post.
And improvements? You want improvements? Dream on:
Over the last few years, drug-makers have embraced a startlingly simple tactic for fending off competition from generic brands: paying them off. In a nutshell, the company that holds the patent on a profitable drug strikes a deal with the maker of the cheaper generic brand: you hold off on marketing your generic for several years, and in return, we'll give you a share of our profits on the drug. ...

So common have these deals become lately that they've been given a name: pay-for-delay. The approach - a textbook anti-competitive tactic - is worth billions to drug-makers, because it essentially allows them to buy more protection than their patent confers.
Recently, the FTC has been filing suit to block such deals, but it's clear that Congressional action is better so the agency is trying to get such a provision into the health care bill. How more obviously justified and straightforward can a proposal be? Still, says TPMMuckraker, "The fate of that effort is uncertain." (Emphasis added.) Because cost-containment is only important where it doesn't affect corporate profits.

Oh, but there is still that saving grace, isn't there? The public option!

Well, yeah, you know about that, I expect.

The recent talk was of a brand new, shiny, polished, never-been used compromise that would involve jettisoning the so-called "public option," long since so emaciated - make that eviscerated - even in the House bill that it no longer deserves the name, in return for lowering the age for Medicare enrollment from 65 to 60 or even 55 and raising the ceiling from Medicaid eligibility from 133% of federal poverty level to 150%.

Those changes are not in themselves bad, but at the same time the limits involved are not insignificant. The Medicare option would only be available to those who otherwise lack affordable insurance, sharply limiting its potential. It might be limited to those who would qualify for high-risk insurance pools already part of the bill. That would limit the group to about three million people - who could be facing annual premiums of $7,600.

One source, which I can't locate just now, said the number of people eligible was small enough that there would be little impact on competition and so on affordability. Which is likely true not so much because of the number of people (there are about 36 million people in the US between 55 and 65, so three million is about 8% of that total - not a huge potential market share but not nothing either) but because of the "otherwise lack" restriction, meaning these are people for whose business the insurance industry is not competing in the first place. (What was I just saying about cost containment?)

And while an expansion of Medicaid would be good, bear in mind that the federal poverty level is a piddling $22,000 a year for a family of four and a typical family of that size would have to make between $29,260 (133% of poverty level) and $33,000 (150% of poverty level) to be among the newly eligible. Again, the increase would be good on its own merits, but I can't imagine it affects a large number of people.

But even those limited and justified-on-their-own-merits proposals are meeting opposition. (The "justified" adjective, I can't help but think, being a good part of the reason why.) So the next "New! Improved!" brilliant idea is to replace the remaining shell of a public option with the idea of having private insurance companies sell national, non-profit plans, regulated by the Office of Personnel Management, which oversees health benefits for federal employees - with no indication of what happens if no private company is interested in selling a non-profit plan. (Just why would they be?)

For those of you still wondering "Huh? Wha' happened?" to the strong public option that was the original idea, here's a good part of what:
President Obama evoked Franklin Delano Roosevelt and the creation of Social Security today in a rare weekend meeting with the Democratic caucus, in a bid to keep his party united behind a historic health care reform bill currently being debated on the Senate floor.
However, it turns out that President Hopey-Changey didn't even mention the public option in his rousing "Win one for the Gipper!" speech. (I suppose I should have made that his "Fired up! Ready to go!" speech.) As many of us have been saying all along, he has shown no interest in having a strong public role in health care (subsidies for insurance coverage that amount to taxpayer payoffs to insurance companies do not qualify); his interest is in passing a bill and he's not prepared to expend any energy securing such a public role, even one as limited as a weak public option (and, again, just saying "he'd like that but hey, you know, let's see what happens" does not qualify as expending energy).

That's clearly reflected in the statement of Budget Director Peter Orszag, who said at the National Press Club this past Wednesday that just about every possible public option compromise is on the table and refused to get into specifics about what the administration prefers in the health care plans.

(Orszag also insisted that the fine for not having insurance coverage that would be part of an individual mandate was unimportant because having insurance will simply be a "social norm," so everyone will buy insurance just because, well, that's what everyone does. He cited seat belt laws as an example, which strikes me as pretty lame support, but that's what he said. He also blew off questions about the public option and why single-payer was never considered by saying people aren't looking at "the bigger picture.")

So, bottom line, at the end of the day and all that, what have we got under this bill? How is it shaping up? How about at least four years of rate hikes, pre-existing condition denials, recissions, and continuing stratospheric drug costs in exchange for locking in the dominant position of private insurance companies, bogus promises of limits on out-of-pocket expenses, no realistic expectation of enforcement of the bill's provisions in the face of corporate interests, a huge new taxpayer-supported market for the insurance industry, and maybe token expansions of Medicare and Medicaid in a package that even according to its own supporters will leave 18 million people uninsured ten years from now. I'm just thrilled.

But wait! On the upside, hey, it does include money for abstinence-only sex education programs despite its demonstrated failures. So I guess it's not so bad.

Some Footnotes, Starting With An Observation: We keep hearing about how many more people will have insurance; with the Senate bill, the figure is about 30 million ten years from now. But what we don't hear about is how many of those people will have newly gained access to adequate health care via such insurance. Put another way, how many of those newly-insured people weren't insured because they couldn't be and how many because they didn't choose to be? How many of that 30 million are the result of the mandate to have insurance, not because of a new ability to have it? I don't know what that figure is; I have seen various estimates over time - none of which I can pinpoint at the moment - as to how many of the uninsured are that way because, for example, they are young, healthy people who have decided that the savings on premiums are worth the risk of being uninsured. The central point for me is and always has been access to adequate health care. And just saying how many more people will have insurance which they did not have previously does not tell us how many more people will have access to health care which they did not have previously.

Some Other Footnotes In No Particular Order: Under the "Try it, you'll like it" heading comes
[a] recent study [which] found that 90 percent of Canadians support universal, single-payer health care. [And a] poll taken last summer shows 82 percent of Canadians believe their health care system to be better than the US's, despite constant grumbling about waiting times for treatment of non-life-threatening conditions.
- Apparently, Harry Reid teed off on some of the stalling tactics being employed by opponents:
"You think you've heard these same excuses before? You're right. In this country there were those who dug in their heels and said, 'Slow down, it's too early. Let's wait. Things aren't bad enough.' - about slavery," Reid said.
Michael "Wazzup" Steele demanded an apology which Reid spokesman Jim Manley blew off as "feigned outrage."

I can't help thinking that if Reid had acted like this from the beginning, things would have been quite different now.

- A new study by the George Washington University School of Public Health and Health Services confirms that the Stupid Amendment will have an industry-wide impact, over time eliminating coverage of abortions for all women.

- One "longstanding media taboo," as FAIR calls it, remains intact: The unwillingness to really look at the corporate tit-sucking in which so many of the opponents of decent, universal health care are so heavily engaged.
In what the Washington Post (7/6/09) referred to as “a record-breaking influence campaign by the healthcare industry,” $1.4 million is spent on lobbying every day. According to the Center for Responsive Politics, lobbying expenditures for all health and insurance sectors total $263 million so far this year, while those sectors have directly donated more than $23 million to federal lawmakers.

Some of the greatest beneficiaries of these donations also happen to be pivotal arbiters in the shaping of healthcare legislation. Yet corporate media have rarely raised the issue of these lawmakers’ potential conflicts of interest. ...

To be fair, a few reporters did follow Deep Throat’s advice [to "follow the money"], producing substantive examinations of the role of money in the healthcare debate—notably the Washington Post’s Dan Eggen (e.g., 7/21/09). A handful of articles documented that conflicts of interest in the healthcare debate are not confined to just a few members of Congress, and not limited to campaign contributions. ...

But such reporting, given the volume of healthcare coverage, was scarce.
- Finally, just for some laughter among the ruins, go read this.

Updated with the breaking news that Tuesday evening, Harry "Mr. Dynamo" Reid said the Gang of 10 had reached "broad agreement" on the public option business - but it's not yet clear just what that agreement is. I looked at AP, the Washington Post, The Wall Street Journal, McClatchy, Reuters, and CNN. There seems to be general agreement that under the agreement, the PO was ditched in return for opening up Medicare to those 55-64; most of those sources indidcate that the idea of an OPM-regulated "non-profit" private insurance plan is also part. In addition, the WaPo said that a regulation setting the medical-loss ratio (the minimum percentage of income from premiums which companies must expend on actual payouts of benefits) at 90% was included.

However, CNN quotes Russ Feingold, one of the 10, as saying he would not "support proposals that would replace the public option in the bill with a purely private approach." And Rachel Maddow quoted Reuters as having reported just after 9 pm (although I don't find it online) that Reid said that reports that the PO had been dropped were untrue. So it's not clear what the agreement is, only that there is a tentative one which has been sent to the CBO for economic analysis.

What I found notable that of the six sources I checked, only CNN and the Post even mentioned the expansion of Medicaid and both in ways that emphasized the opposition. Apparently once again poor people are the afterthought.

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