Wednesday, March 24, 2010

Regular length observation

So, with a perhaps historic number of invocations of the word "historic," the bill is law. Whoopie.

I'm not surprised something passed; I've been saying since at least the beginning of November that "we will get a health care bill - the absence of the word 'reform' is deliberate - this session of Congress" because, as I said a month later,
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.
But I simply can't get excited about it, for all the reasons I've tried to explain before now. Not only is this bill not good enough, it's not even as good as its proponents proclaim. And despite all the "first step" rhetoric, it does more to impede real reform than it does to advance it.

No, of course I'm not saying that there is nothing good in the bill; don't be a jackass. The ban on lifetime limits, for example, is a good thing - assuming the reconciliation bill, which removes the Senate bill's exemption for employer-provided health plans, is passed as I expect it will. (Lacking that change, the limit essentially only applied to new coverage, not any coverage you already had.) For a prime example of something good, I think the expansion of community health centers is great. In fact, I think that provision does more to expand access to health care - and, as we often forget, it is access to health care, not access to health insurance, that is the real issue - than pretty much anything else in entire bill. (And I admit to a certain dark pleasure in seeing so many of the bill's supporters, including some of the most strident, now saying "Well, it's not perfect, of course, but you know...," now casually admitting to shortcomings whose existence or relevance they previously vociferously denied.)

But you don't get to pass just the good parts of a bill, you pass the whole thing and it's the whole thing, the whole package, on which judgment must be passed. And on the whole, the bad parts of this clearly outweigh the good - especially since the "good" isn't what it's cracked up to be, as the unfairly-maligned Jane Hamsher* (Remember when she was the big hero as one of those live-blogging the Scooter Libby trial?) pointed out recently.

I've gone through a lot of these same points before, so just to cite a few specifics:

- Even judging by insurance access, the bill falls seriously short: The plan will leave nearly half of the currently uninsured (24 million of 54 million) still uninsured nearly 10 years from now with no plan to get them coverage.

- It does not control costs: The CBO score from November indicated essentially zero effect on premiums in 2016 and the CMS said in December that it would reduce overall spending on health care by a minuscule 0.3%.

- It does not make health care more affordable; rather, it simply forces people, many of them already struggling to keep body and soul together, to buy insurance which they may not be able to use because they can't afford the deductibles. (Parenthetical personal note by way of illustration: Because of our own particular circumstances of income and mandates, my wife has been forced onto a plan which demands a deductible of over $9,000 in a six-month period before she obtains any benefits. No, that is not a typo, an exaggeration, or a joke. Well, it is a joke - just not the good kind.)

- It does not stop rate hikes. At all.

- It does not stop recissions.

There's an additional point about recissions. Hamsher notes that there is no functioning or proposed enforcement mechanism to control the insurers. But she does not mention that the bill - unless it was changed at the last minute - allows for your policy to be canceled in the event of fraud or willful misrepresentation. That has been the law since 1996! Insurance companies still cancel policies by finding some excuse, some detail, they can claim amounts to fraud or misrepresentation. Just what is to prevent them from continuing to do exactly that?

There are other areas where the bill falls short of its advertising. One such not on Hamsher's list is that while it's true that after 2014 you can't be denied coverage or charged more for a pre-existing condition, but until then, you can - and there's no indication that at that time those rates would be cut to those others pay on a policy you already have. So expect a lot of approvals for people with pre-existing conditions with jacked-up rates over the next few years, with people continuing to pay those higher rates even after 2014. Even after that time, you can be charged up to triple based on your age and 50% more if you smoke. (So much for community rating.) And you'll have no choice but to pony up because, of course, you get penalized if you don't have insurance. Unless, that is, you decide you'd be be better off just paying the penalty - which still leaves you worse off than you were, paying a penalty and still having no coverage.

And again, that's not even the bad stuff, that's just some of the "not as good as advertised" stuff.

The bad stuff comes in two broad categories, the practical and the political, if you will, which then can be combined into one overriding concern: It will, as I have said before, as I said at the top here, do more to impede real reform than to advance it. First consider the practical aspect, expressed clearly in the words of Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine:
What this bill does is not only permit the commercial insurance industry to remain in place, but it actually expands and cements their position as the linchpin of health care reform...Not only does it keep them in place, it pours about $500 billion of public money into these companies over 10 years....
(Thanks to Tim at Green Left Global News & Info for the link.)

All while continuing the industry's incredibly bizarre anti-trust exemption. That is, it actually increases the power and control of the health insurance industry, creating an even bigger barrier to be surmounted before real reform could be achieved.

It wasn't just the insurance industry that cemented its place: The deal the White House cut with the pharmaceutical industry last spring, in which the drug pushers agreed to $80 billion in savings for seniors over 10 years in return for no drug reimportation, no shorter pathway to generic biologics, and, most importantly, no Medicare drug price negotiation (which together could have saved nearly $400 billion over that same time) is pretty well known. More recently, we have confirmation that Obama struck a similar deal with lobbyists for the hospital industry in which he promised, despite his what were apparently persistent lies in public, that a public option would not be part of a final bill.

That overlaps the political part of the problem: The bill strengthens the position of the existing players on the supplier side and creates no counterbalance on the consumer side. Meanwhile, there are already moves, of which I'm sure you're aware, to challenge the plan in court and the GOPpers are planning to run on a platform of repeal. That the court cases are likely to fail and that even David Frum thinks it's "a good bet that conservatives are over-optimistic about November" changes nothing: Taken together, this still means that in the short run and in fact for some time to come (especially if the persistently-pessimistic Digby is correct) any available energy will go into defending what is rather than into improving it.

So in the short term we are going to hear a chorus of "Health care reform? We did that! Stop looking backward! We need to go forward! So move along! Don't harsh my buzz, dude!" Over the next couple of years we're going to get lectured on how "The program isn't even in force yet and you're attacking it, siding with the right wing! What's the matter with you?" After 2014, that will shift to "It's just getting started! Give it a chance! What, are you rooting for it to fail, you closet right-wingers?" And in 2019, when the plan is supposed to be "fully in force," we'll be told - if anyone is still talking about it - that those of us pointing to the failures of the system, to the tens of millions still without coverage and the scores of millions still without access to care, to the continuing need for actual reform, are "impractical dreamers" who believe in "magic ponies."

And no, don't bother telling me about the "pathway to state-level single payer." Yes, there is a waiver provision for states to opt-out if they can show they can provide the same or better care for no more money than the structure under the bill. But the waiver is nothing short of bogus. First, it's not available until 2017, meaning that in order to do this states would have to set up exchanges, run them for three years, they take them apart again for a new system. It's doubtful any state would want to or be in a position to take on that extra expense.

Just as serious if not more so, the waiver would require the approval of the Secretaries of HHS and the Treasury - but to waive ERISA, which bars states from telling employers and unions what kind of insurance to offer, you need the approval of the Secretaries of Labor and the Treasury. That is, this "pathway" does not allow for waiving the requirements of ERISA, thus leaving any state which did try to opt out in favor of a single-payer plan vulnerable to suits by the insurance industry, not to mention any business interests in the state which may oppose the idea.

(As a parenthetical sidebar, I don't think Bernie Sanders, whose proposal this was, intended to create a bogus option. But he did anyway.)

So the bottom-line fact is that those who imagine that a Congress which won't even acknowledge the existence of the idea of a national health care system, that for year after year after year has refused to even consider single-payer and declared it "off the table" at the start of the current debate, that slapped down even the great-sounding but actually rather lame "Medicare for all," who imagine that that Congress is now going to embrace anything like that because this half-assed thing was passed first and will do it in the face of an administration that is committed to keeping even the wimpiest version of a "public option" beyond the pale, an administration lead by a president who, I said nearly a year ago,
is trying to resolve the crises and shore up the institutions while changing as little as possible about the logic or principles on which they're based,
a president who has shown by his willingness to cut deals with lobbyists that he will forsake public interests for the sake of private interests, if they believe that this bill will be used as a "foundation for change" rather than a ceiling for it, if they believe that its very existence will not be used as a basis to delay and dismiss calls for real reform for the next couple of decades, then I say they are the ones who genuinely believe in "magic ponies."

And if time proves me wrong, throw this back in my face. I guarantee you that in that event I will be a little embarrassed - but not the least bit unhappy.

*If she's going to be maligned for something, it should be for her involvement in "Natural Born Killers."

Footnote A: In that November 1 post linked at the top, I said in reference to a coming health care bill that
[i]t increasingly looks like it will be a bill that will require people to buy insurance, will put no restrictions on the insurance industry (which is more than happy to do away with pre-existing condition exclusions for the sake of getting tens of millions of new customers) but will instead provide the industry billions in indirect taxpayer subsidies through subsidized premiums, provide no meaningful competition, create a "public option" not worth having, undermine state-level drives for single-payer, set back real reform by at least a decade, and 10 years from now will still leave 18 million uninsured and an unknown additional number underinsured, all of them without access to adequate health care.
It actually turns out that there is no "public option" and there will be 23 million still uninsured rather than 18 million - but other than that, I think I did pretty good.

Footnote B: I think I should explain why I labeled "Medicare for all" as "rather lame." Medicare is a good program, valid on its own merits, but contrary to frequent assertion it is not a real single-payer program - not when many of those covered under Part B have secondary supplemental insurance and Part D is a mish-mosh of private plans. People covered by Part B often find that after deductibles and co-pays, Medicare actually pays only half the bill. Again using my wife as a case in point, we calculated that allowing for her eight regular medical visits and related tests a year, after allowing for deductibles, co-pays, and the costs of Part B premiums, it was cheaper to pay out of pocket than to have the insurance. "Medicare for all" is a decent enough slogan, but as an actual program it is not a substitute for genuine health care reform.


Jenny said...

Didja see what Richard wrote? Whadya think?

LarryE said...

I'm not sure which post you're referring to. If you meant the "Going down with the Titanic" one, I think he's quite right that the unions were wrong to cave and support the health care deform bill because of some token concessions (that raised the value of policies subject to the excise tax and delayed implementation) but, as he too often does, wrote with a club rather than a rapier about the potential consequences.

If you mean the most recent "What now" post, I just wrote this comment there:

A personal policy of saying I want to put my time and my energy and my money to causes in which I believe and not let someone else decide for me is a sound basis for ethical political decisions. I would only caution against what I have seen so many times over the years, where "decentralization or death" has become "decentralized to death." One group subsuming 1000 voices into one will always be something less than the sum of its parts and never be truly representative of the whole - but 1000 groups of one voice each will always be something less than effective.

The point, I suppose, is where you draw the line - and I guess that has to be an individual judgment.

Does that answer your question?

Jenny said...

Yes, it does. Thank you and I apologize for not specifying.

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