Wednesday, August 12, 2009

Healthcare reform questions

This will probably degenerate into a flame war, but I hope it doesn't. (This one time) stirring the pot is not my intention. :)

I've read through the bills and analyses and I must say, my biggest question is "What problem are we trying to solve?" I know healthcare is "broken" but we all seem to have different definitions of what "broken" means.

It appears that a big goal of the proposed healthcare reform is to reduce the number of uninsured. Is that right? And, if so, will the reform actually achieve that goal? The Whitehouse.gov site says: "Assure affordable, quality health coverage for all Americans" But what does "affordable" mean? I mean if I spend my money on Xbox games, then I can't afford health insurance. So how do we define "affordable" and what makes it not "affordable" today? Will the new plans really be more "affordable"? Why? How? In what way?

My take is that this reform is too much of a compromise and will end up not doing a whole lot, with a lot of potential for unintended consequences. It seems to be more of a health insurance consumer protection act than healthcare reform. As I read it, it sounds like it may help the uninsured at the expense of the rest of us.

Obama has promised, and the proposal states, that if you are satisfied with your current plan, you can keep it. However, your current plan must be a "qualified plan". The New York Times article A Primer on the Details of Health Care Reform quotes Dallas L. Salisbury, president of the Employee Benefit Research Institute, a supposedly nonpartisan group:

“The president and Democrats in Congress are saying what they would like [that people can keep their current insurance]. Their promises may not be literally true because your health plan may change, and your doctor may no longer accept your insurance.”


Regarding all the scare tactics from right-wing crazies about euthanasia and "death panels", even the AARP says “The rumors out there are flat-out lies.” So don't even go there, please.

I am concerned about one of the issues raised by the right-wing (and others): the potential impact to Medicare. Proposed cuts to Medicare account for nearly 40 percent of the bills’ cost (that's a lot of how the reform is so-called "deficit-neutral"). Obama says these cuts will not reduce Medicare benefits, but if you're taking $150 billion out of the system (over 10 years), one has to believe some things will change, that some doctors and hospitals might stop treating medicare patients on the new payment terms, etc.

But again, back to my original question: Can someone tell me what specifically this proposed reform is trying to fix (as opposed to in the general statements from the Whitehouse.gov website like "Improve patient safety and quality of care")?

12 comments:

TBoss said...

I haven't waded through much of the proposals yet so I can't speak to whether or not any of these issues are addressed (or "adequately" addressed), but here's the big ticket items I want to see fixed:

1) Rescission. Today your policy will be canceled if you start requiring too much healthcare.

2) "Creaming of the Crop". If you are in a group plan and start making a lot of claims, the insurance companies create a new group plan for the healthy people and move them over to it. The small number of sick people left in the old group must now cover all its costs, which of course will be prohibitively expensive.

3) Denial of care for pre-existing conditions. Let's face it, eventually EVERYBODY has a pre-existing condition. Ultimately that's why we get health insurance in the first place.

Mr Blog Too said...

Tim, I think based on these items, then you might like the reform bill(s). However, of course all "fixes" come with a price, so don't be surprised if your rates go up and if your doctors refuse your insurance. :)

Both the House bill and its sister bill in the Senate try to address these issues, in various ways, in some cases, ways that I would cast as somewhat "indirect" or "soft".

The House bill under consideration regulates insurance through insurance exchanges to eliminate “rescission”, caps out of pocket costs (thereby ending the medical bankruptcy epidemic), provides subsidies for middle class families (earning up to $80,000 for a family of 4), and creates a public insurance option which is the "catch-all" to keep the private insurance companies honest (yeah right).

Bradley Martin said...

Last year Providers (Doctors) took a 10% reduction on payments from Medicare (but I'm sure their expenses didn't)
So if Medicare payments are cut further, there are a number of Providers that will be forced to drop their Medicare contracts (and vicariously their patients) and move to fee-for-service (which, overall, will also create an increase in cost to care).

There is a solution to this problem of the uninsured/uninsure-able, and I guess too simple to be considered by Congress.

Each Insurance company has a measurable market share. Based on their market share, they should be required to 'on-board' a like percentage of the uninsured/uninsure-able. Therefore, each Insurance company proportionately shares the same "risk" (banks have similar requirements with lending laws).

This new group of uninsured/uninsure-able are placed under a capitation plan with the Insurance company; subsidized by the Government. Additionally, this plan would include a co-pay program. Co-pays would be determined based on the individuals ability to pay as well as on their successful adoption of their Providers care instructions (preventative care and current care). This co-pay program is thereby designed to off-set (albeit only partially) the increased cost of care caused by an individuals choice not to adopt or participate in preventative care and current care programs.

Some will see this last co-pay bit as intrusive and a violation of civil rights; however, there should be an incentive to remain on a private (free market) plan. Further, if you are ignoring the medical advice of a Doctor and becoming a greater burden to the tax payer, Provider and Insurance company, there should be some balancing to that additional burden.

Just my two and half cents...

TBoss said...

Bradley, your idea tries to address insuring the uninsured / uninsurable, but how does that address my three issues? I can afford insurance, it will just likely get canceled if I ever actually need it. How does your plan deal with rescission, creaming-of-the-crop, and denial of care for people with pre-existing conditions?

Bradley Martin said...

My plan is a 20,000 foot view but consider the following:

Why would the insurance company move you from the fully funded plan you have today into a partially, underpaid plan that has heavier government oversight? I don’t believe rescission would remain cost effective. Additionally, moving people around in plans, in an attempt to avoid costs or to increase revenue may remain an issue; but I believe less so, if people can then opt into the Government plan that costs the insurance company more. And denial of coverage due to pre-existing condition is the uninsurable, so we cover that in our plan as well.

And if I may just quibble over one a small point, one is not denied "care" because of pre-existing condition; one may be denied coverage. Health care is not broken in this country; health coverage is. I understand the argument that to receive Care it helps to have Coverage; and with MediCare/MediCaid/MediCal and the myriad of charitable organizations out there Care happens (it’s not perfect; but perfection might require we erase free will from all humans and become subservient to the Robot Overlords from planet Omega 9).

Brian Yoder said...

Rather than figuring out how to get the government into more control over the the problem, we ought to be focused on undoing the problems that the government have already created and allowing us to solve our own problems. Specifically, I think we should make some improvements along the following lines:

1. Allow individuals to deduct their insurance premiums just like businesses do. They should do the same thing for Heath Savings Account contributions too. This will encourage more people to buy their own policies rather than having the HR department make their decisions for them and it will allow intelligent trade-offs to be made between costs and benefits. It would also allow a little more sanity to enter into paying for small medical expenses rather than assuming that insurance should pay for everything no matter how small.

2. Change medical malpractice laws to take recognition of the fact that many medical procedures are inherently risky and even under normal circumstances the results won't always be what we wanted. If individuals want to take out "bad consequences" insurance for whatever amount to cover such things there should be nothing to stop them so long as they pay the price. The law should however be somewhat more harsh in cases of actual cases of complete irresponsibility than they are now. If a doctor is caught operating while drunk or similarly completely irresponsible behaviors they ought to be criminally liable and punished accordingly rather than just enriching the lawyers who can weasel out some kind of liability case as they do now.

3. If people can't afford insurance then let's cut their taxes until they can. If we boosted the standard deduction by the cost of a typical catastrophic insurance policy anyone who wants insurance can get covered for serious medical expenses unless they are very poor and the very poor already have Medicaid.

4. State insurance boards dramatically increase the cost of insurance in many places by requiring expensive items to be added to all coverage. At very least the government could allow people to buy insurance from whatever state they want to avoid these busybodies from limiting consumer choice in cost and coverage.

5. There is also a huge amount of pretty useless and counterproductive law regulating insurance, health care, drugs, and medical devices that we would be better off without. Since we are talking about thousands of laws with thousands of implications I can't summarize in a simple way all of the ways they can be trimmed back but someone ought to do that one way or another. Perhaps one way to do that would be for the government to recognize (perhaps through a Supreme Court ruling?) that there is no constitutional power for the federal government to provide medical care for anyone or to regulate the industry at all. Then every law would need to be reconsidered on the basis of whether it can be justified through some legitimate government power (for example, you could say that insurance for government employees and the military is justified under the provisions that create those powers). One that I would sorely like to see go by the wayside is HIPAA. What a colossal waste of money and time that is!

With a little more personal control over the money and the consequences things would be a lot better than if we hire a million more bureaucrats to "help" us with our medical care problems.

Anonymous said...

@Brian. Well said.
a truely free market system should be the goal. I don't think Congress is "progressive" enough; nor do I see the current administration adopting truly "free market" concepts.

I've heard of Capitalism; I had to asked my parents what it was like?

Henry Blodget said...

Paul Krugman http://www.nytimes.com/2009/08/17/opinion/17krugman.html notes that "every wealthy country other than the United States guarantees essential care to all its citizens"--except us.

Here are the options that these other countries have selected:

Nationalized healthcare. E.g Britain.

Nationalized health insurance. E.g. Canada, France.

Private insurance with strict rules to make sure that everyone's covered. E.g. Switzerland

Obama is essentially proposing that we move from our system to the Swiss system: Private insurance with rules that make sure that everyone's covered.

Everyone who is trashing Obama's healthcare plan should be required to choose (a) The status quo, in which we remain the only wealthy country in the world in which basic healthcare isn't guaranteed, or (b) one of the options above that work for the rest of the civilized world.

Mr Blog Too said...

@Brian, I like your ideas, in the abstract. I'm always for trimming out useless laws and regulations (how about generic "Sunset" triggers for all laws?) but I'm not sure it has any practical chance in hell of happening, or whether if it did happen, whether it really achieves all the goals @Tim discusses. One problem with (3) is if I'm not making any money, there are no taxes to cut.

@Anonymous (if that, indeed, is your real name) I'm all for Capitalism but the "free market" model has not worked across a wide spectrum, well beyond healthcare, , and I'm sick of hearing about it because now the term has come to mean nothing more than "I watch Glenn Beck and I believe everything he says." I'm all for Capitalism but I this "no government, ever, at any price" policy is broken. I accept the reality that some amount of regulation of Capitalism is required.

Denny said...

The masquerade is over! The "public option" is ... dead.

Health care reform is now a private option: WHICH FOR PROFIT INSURANCE COMPANY DO YOU WANT? You have to choose. And you have to pay.

The Administration plan requires that everyone must have health insurance, so it is delivering tens of millions of new "customers" to the insurance companies. Health care? Not really. Insurance company care! Absolutely. Cost controls? No chance.

Support HR676 "Medicare for All" instead. The bill now has 85 sponsors in the House.

The hotly-debated HR3200, the so-called "health care reform" bill, is nothing less than corporate welfare in the guise of social welfare and reform.

Removing the "public option" from a public bill paid for by public money is not in the public interest. What is left is a "private option" paid for with public money. Why should public money be spent on a private option which does not guarantee 100% coverage nor have any cost controls? A true public option would provide 30% savings immediately which would then cover the 1/3rd of the population who presently have no health care.

Unfortunately, under HR3200, the Government is choosing winners and losers in the private sector; proposing to spend public funds on subsidizing insurance companies who make money not providing health care. This process will insure only the expansion of profits. Gone is the debate over cost.

TBoss said...

These are some excerpts from a long rant I sent a a friend of mine....

My biggest problem with our current health system is that the companies who run it exist for one reason and one reason only: to deny health care. I don't know if you watched any of the testimony on CSPAN, but they had a parade of health insurance company employees testifying about what they do for a living: they deny health care claims & treatments, and cancel policies. Their pay and bonuses are directly linked to how much health care they deny. They can be (and are) fired for approving care. That's why I'm so bemused when people say "I don't want some bureaucrat telling me what care I can & can't get." They already have a bureaucrat doing that, the only difference is that the current bureaucrat is doing it for a profit, whereas a government bureaucrat could potentially have the job of PERMITTING health care rather than denying it. And with a government bureaucrat I would have the option of writing my congressman or senator if I felt I had been treated unjustly. With a health insurance company you have no recourse. You have to agree to binding arbitration to get a policy. The insurance company gets to choose the arbitrator. The arbitrator depends upon the insurance company for his income. If he rules against them, he gets blacklisted and will never be hired by any insurance company ever again. I can't site a source right now, but I have read repeatedly that so-called "neutral arbitrators" rule in favor of the insurance companies 85-90 percent of the time. They have to or they become unemployed.

I already know that the health insurance companies have won. There will be no reform. It will business as usual for at least another 20 years. I guess the problem is a simple statistical one: As an insurance company executive testified to congress "80 percent of the people are completely happy with the system as it is." That is completely true: 80 percent of the people are healthy and do not need health care. The 20 percent who are unhappy are the ones who finally needed care. Once people cross that threshold from the healthy who need no care to needing care, they become part of the 20 percent who are dissatisfied. So a majority of the public will never be in favor of reform so long as the insurance companies continue to successfully mount "fear campaigns".

Bradley Martin said...

Well if I have to have a health insurance like I have to have car insurance, then I want an insurance commissioner.  though, I’m not yet convinced the car insurance analogy works; I have always been told driving was a privilege and the roads I drive on are by and large paid for by the public sector; and one always has the choice not to have a car and thereby no requirement for insurance… but I understand Tim’s point… so I think a health insurance commissioner is a good idea; and I’d rather see it at the State level; the Federal government and I are too far apart. At the State level you have a better chance of being heard.