Posted tagged ‘health care reform’

Mandate, Tax, or Penalty?

July 3, 2012

The Supreme Court has ruled most of the Affordable Care Act as Constitutional.  The Court focused on the “individual mandate” rightly as the lynch pin for ACA.  Was this provision to require all Americans to have insurance a mandate, a tax, or a penalty?

The Court ruled this provision a tax but since the ruling any pundit still breathing has voiced opinions seemingly split between the three.  If this wasn’t such an important issue, this argument would be hilarious.  As it is, the differing opinions only underline the Country’s naivety around health care.

Healthcare as was in force prior to the Affordable Care Act, including Medicare and Medicaid, were costing the country a fortune and were escalating in costs at 2-3 times inflation.  Also at that time, insurance providers could, at their discretion, deny coverage to anyone with a pre-existing condition or who had already consumed more benefits than some stated amount (lifetime spending limits).  There was no question that in the near future health care would become affordable to few and fewer Americans.  Lastly, the American health care delivery system was the largest in the world.  The US was spending almost two times per capita that of other first tier of modern industrial countries like Germany, France, and Japan.

Affordable Care Act has many provisions and claims that it will bend the cost curve.  (The CBO agrees.)  Unfortunately, health care costs will remain high relative to other successful models for a long time.

What changes, however, is access to health care.  Affordable Care Act provides means for 30 more million Americans to obtain insurance and prohibits practices such as pre-existing conditions and life time spending limits.  In short, ACA deals with the moral and ethical side of health care delivery.

Listening to the trash talk surrounding tax, penalty, and mandate, one must wonder what people are thinking?

Some may honestly believe that if the government “gives” people something, they are really doing those people a disservice.  Maybe like buying an alcoholic a drink.  Others may simply be more crass and say I don’t want my money going to pay for someone else, let them get a job and pay themselves.  And some hold no beliefs but see controversy as a means for their personal wealth enhancement… like pushing a message through a Super Pac for later political gains.  So…

“The ACA is the largest tax increase ever….”  Wrong, ACA counts the sale of new insurance coverage as well as any “penalties” for those choosing not to buy coverage.  More people covered, more money.  No one with insurance pays more due to expanding access, but with more people covered, there ought to be more revenue.

“The ACA will rob seniors of $500 billion in Medicare reductions….”  Wrong.  ACA projects with various cost control and procedural changes that Medicare will still spend more than today but less than previous law had projected.  What do critics want?  Should Medicare forget about reform and just spend the money anyways?

“ACA is putting the government between you and your doctor….”  Duh?  Today the insurance companies stand between you and your doctor.  What’s the difference?  Insurance companies are extracting at least 20 cents for each dollar of medical expense and Medicare extracts about 5 cents.  Hmmm.

Not to be overlooked, ACA keeps all hospitals, doctors, and drug companies private and able to exercise free market principles.  Unfortunately ACA also keeps insurance companies, and they will continue to stand between you and your doctor, although with more restrictions.

The most important reason, however, why the controversy over mandate, tax, or penalty is irrelevant is that ACA does not go far enough.  No amount of “free market” incentives will drive down health care costs while maintaining or improving outcomes.  Ask Germany, France, Japan, or most other modern industrial country.

Sadly America is not ready for that discussion.  There is too much at stake and health does not play any role in that debate.  If we are to reduce per capita health care costs from 100% more than the pack to say, 50% more, we are looking at $700 billion coming out of hospitals, doctors, drug company, and insurance providers’ pockets.  That is a lot of money.

The day will come as sure as the sun will rise tomorrow.  The only question is when.  Until then, is it a mandate, a tax, or a penalty?

Is All The Buzz A Wake-up Call?

March 28, 2012

Listening to the many news reports on the Supreme Court “Affordable Care Act” deliberations, one almost wonders what one is hearing?  Is this America?  Is this taking place in the world’s wealthiest country?  Doesn’t anyone see what’s happening?

The Supreme Court is about to rule on Constitutional limits of Congress, not how to provide minimum adequate health care.  They have left the reservation and some Justices seem set to rule without regard to the greater context.  If the Federal Government can not regulate the health care industry, who then can ensure that each and every citizen can access basic health care.  Who can keep this vital service from bankrupting individuals first, and the country second?

When President Obama addressed health care reform, a strategic decision was made.  Rather than expand a national program like Medicare, the Obama Administration concocted a plan based upon the current “for profit” insurance companies.  This was an unfortunate choice for health care but understandable from the existing business model.

The Obama Administration promised insurance companies more customers (from the individual mandate) and in return, the insurance companies promised to not deny coverage for pre-existing conditions and to agree to offer higher risk individuals the same low rates equivalent to other average individuals.  A deal with the devil often does not turn out the way you want.

Now the future of the Affordable Care Act hangs at the mercy of an esoteric deliberation.

A “no” from the Court will mean mass confusion with thousands and thousands again back on the no insurance road.  These individuals will still get treated (emergency rooms) and those costs will still flow to all the rest of us.

There is another aspect of Affordable Care Act that should be of interest.  This provision expands Medicaid coverage significantly.  In this land of wealth, why should so many people (earning less that $20,000 per year) be in need of Medicaid?

The fundamental issues which is not part of the discussion, is how can such as rich country as the US not view basic health care as a right and instead a playground for profit making middle men?  You can not help but ask, also, why are there so many people who can’t afford insurance coverage and must rely on Medicaid?

I wonder why no one is asking these questions?

Draw The Line

April 8, 2011

President Obama is facing a rotten choice.  He must decide whether to draw the line and reject the Republican demands for extending the debt limit (pay ransom) or most likely face a Government shut down.  This could be a damned if you do, damned if you don’t decision.

We all know what Obama did when faced with the “let the Bush tax cut for millionaires” decision.  He caved.  (President Obama did get some stimulus relief for the deal, but selling no tax cuts for millionaires should have been easy.)

This time the President is looking at Republican demanded cuts to Planned Parenthood, Public Radio, and implementation of his health care reform bill.  You might notice that none of these have anything to do with reducing the budget deficit.  Rather they are pure political ideology.

Should the President blink, he will face the same type of uneven approach to spending reductions (take from the less wealthy and give to the wealthy) when the 2012 budget is debated.  The Tea Party segment of the Republican caucus will gladly hold the country for ransom too if their demands for certain cuts are not met.  It will be a redo, only on a grander scale.  This would argue why not now?

On the other hand, if President Obama does draw the line and there is a government shut down, no one knows for sure what will happen.  Even worse no one knows for sure who would be blamed.  Should the economy sputter as a result of a shut down, the 2012 election could be impacted.  Maybe even a one term presidency.  This is a lot to think about.

The real issue here is about where the armistice line will be drawn.  After that is agreed to then the rest can be divided in some fashion.  At stake is which constituencies will be hurt the most when the inevitable cuts are made.

Unless President Obama plans to duck and weave, and give in all the way (in hopes of getting reelected), there is probably no better time than now to draw the line.




February 22, 2011

There is an ethics debate underway.  It may not be phrased that way.  It is more often referred to as an “affordability” issue.  Of course, I am referring to health care and its availability to all Americans.

The affordability side points out that good health care is costly.  They claim that making it available to everyone will mean everyone will have to wait for service.  Some claim “death boards” will decide whether grandma will even get treatment.  And the most honest, if still ethically challenged, will say if people do not pay for health care, they will abuse it.

Like so many of the other political debates, there is truth in much of what is said.  If nothing changes, and you give “free” health care (as we know it today) to everyone, it will be over used.

But why must patients only see doctors?  Why can’t doctors use hand held imaging devices during routine physicals?  Why must doctors feel compelled to order dozens of diagnostic tests when they are not necessarily required?

First, we must recognize that health care under any system is not free.  There are doctors and nurses to pay.  There are hospitals to staff.  And there are drugs and medical supplies that must be purchased.  The question is how much should an individual pay, and in what form should that payment be made.

For example, there are co-pays and the remainder is paid by insurance.  There could be co-pays and the rest paid by the government which in turn raises this money through taxes.  In cases of extreme poverty, the government (read tax payers) could pay for those without means but everyone else would pay.

Second, under any system of distributing health care, instantaneously there will be shortages and some method of allocation (and scheduling) is necessary.  Probably the least cost effective is the one we employ now.  Have enough medical services available to satisfy those who can pay and let costs rise through inefficiencies and fraud.

Getting agreement on this subject is very difficult when those who enjoy great coverage believe they will have to give up this coverage if health care is extended to all.  A clue might come from the German system.

In the German system, everyone is expected to pay into a plan.  Everyone is extended cost effective treatment.  No one is denied coverage.  There is a national plan that supplements citizens contributions from taxes.

In addition, there is “private” insurance.  This layer on top of the national plan allows those who can afford to pay to receive the boutique service (seeing Herr Doctor Professor, or access to a hospital bed in a higher rated hospital).  Pay more, get more.

What keeps this from being outrageously unethical is that the entry level of health care is more than satisfactory.  Germany has one of the best systems in the world.

There are very reasonable paths forward for the US.  They will, however, require changes to our current systems, and the expectations of doctors, hospitals and suppliers.



Customer, Service, and Care

February 21, 2011

Universal health care may not be the slam dunk answer to our current health care problems.  If you have great insurance coverage today, you probably do not see any problems anyways.  But with the US system the costliest in the world, not covering everyone, and with health outcomes below almost all other modern countries, I would still say there is a problem.  But here is a counter argument.

A friend of mine who was quite familiar with the Canadian universal system offered this insight.  He said many working in the Canadian health care system do not look at the patient as a “customer”.  He said that leads to poor bed side manner and a rather aloof attitude about any urgency the patient might have.  He also pointed out that care is not always available when the “customer” might want (or expect) it.  For example, one might have to wait weeks before space was available for chemotherapy treatment.  And, he said, on top of that the canadian system is going broke too.

My friend went on that there are too few doctors in Canada.  He reasoned that since doctors earn far less than their US counterparts, there were simply fewer people willing to practice medicine.  All this lies ahead of any American shift to universal care.

These are certainly outcomes I would not be clamoring for.  Never the less, I keep coming back to the actual situation in the US today.  We ration our health care resources on the basis of ability to pay, plain and simple.  Our system is biased towards emergency treatment as opposed to preventive health measures.  There are far more specialists to try and fix what has gone wrong than general practitioners trying to keep their patients healthy.  Emergency rooms are favored over health clinics.  MD rule the way over nurse practitioners.

I still can not understand the personal ethics behind a health care delivery system that denies coverage to some, charges exorbitant rates to others due to a pre-existing condition, and allows so many children to be without coverage.   There must be a better way.

In the end, everyone is going to die.  Our genes play a big role in when that time might be.  Personal choices, however, often play a bigger role.   Health care, therefore, must be about enabling each person a chance to achieve the optimum “quality of life” the particular individual has a right to expect.  This is a complex subject with many deep ethical questions I am not qualified to comment upon.  Never the less, without basic health care access, some people are screwed from the start.



February 18, 2011

The huffers and puffers are taking center stage in Washington.  There, they proclaim their views on rescuing the Country from the deficit.  Some look to discretionary spending for their headlines.  Others zero in on Social Security and Medicare/Medicaid.  In separation, they all look silly.  In combination, there appears to be the basis for a serious discussion.

For example, why does the country need a second F-35 engine when the Defense Department says we do not?  Or, with life expectancy far above the the 66 years that existed when Social Security was introduced in 1936, raising the eligibility age seems reasonable.

Medicare and Medicaid, however, need a closer look.  We need to agree on what America is about.  Do we believe that when Americans become older and more vulnerable, they should be at risk of medical bankruptcy?  Do we believe that the needy, and especially the children of the needy should be somehow excluded from health care coverage or provided some sub-standard product?

How is it just that Congress members and Federal workers should receive tax payer paid, first class coverage and older and poorer Americans should get less?

The path forward with Medicare and Medicaid leads ultimately to a complete revamping of the overall US health care delivery system.  The current system is out of control on cost and only average in quality when compared all other modern industrialized countries.  Such an undertaking is not in the cards for this Congress.

Rather, we will hear pontifications around means testing, lower benefits, and fraud elimination.  All of which might be worthy “if” and “only if” Congressional and Federal worker benefits were in the same basket.

Maybe pigs will fly.


Laser Focus

February 10, 2011

Republicans have promised to focus like a laser on jobs.  I wonder what kind of laser they were talking about?

Their first legislative priority was repealing health care reform.  Were they to be successful, this would do nothing about health care costs other than raise them. Oh, yes the repeal would once again deny coverage to millions of Americans and leave some 30 million uninsured.

Their next focus was on rewriting the Hyde Amendment by trying to enact legislation that prevents private health insurance from including abortion coverage.  Republicans claim that since in some cases this insurance receives favorable tax treatment, that is the same as a government subsidy.  What?  People with health care insurance receive government help and people who cannot afford insurance or have a pre-existing condition do not?  And by the way, what does abortion have to do with health care reform or jobs?

Now the jobs seeking Republicans are turning their attention to the prospect of what to do with the federal debt limit.  The answer is obvious, of course.  There is no time to put fixes in to reduce the deficit, so the limit will have to be raised.

Not so fast says Representative Eric Cantor.

Any bill that would increase the debt limit, he says, must contain an amendment which excludes any government funds flowing to the health care reform bill.  This type of amendment has a snowball’s chance in hell of surviving the Senate or the White House.  If the Republicans persist, here comes gridlock and government shutdown.

So, tell me again about the laser focus on jobs.