Obamacare, Brave New World revisited

[M&K's Retrievers]

Have you thought about what might happen if you got sick, couldn't work, couldn't pay your premiums, and your insurance got canceled?

Exactly! The system should address those that can't get insurance. Eithor they can't afford it or they are uninsurable. They should be covered by some government program. Providing coverage for those who don't want to pay for it or illegal aliens is not our problem. Don't "fix" something that works for 85% of the population if it's not broken. Get it?

[Gerry Clinchy]

http://www.nytimes.com/2009/08/22/us...html?th&emc=th

As part of this discussion, some have cited the success of the VA health care system. Evidently, it doesn't always operate as we would hope.

Granted $24 million in bonuses is small potatoes compared to AIG and the investment banks, but who was watching the store at VA?

[YardleyLabs]

Having helped to run a publicly owned and operated health care system, it would never occur to me to suggest that as a model for health care. The problem is not government operation, it's segregation between those receiving privately paid care from those receiving subsidized care.

When you create a system dedicated to serving a secondary population that is run by people who do not use the same system, you end up with second rate health care. Nursing homes that serve only Medicaid patients are paid as much for care as nursing homes serving private patients. However, they provide poorer care. In New York City, the city owned hospitals have physicians provided by the top medical schools in the country, the same physicians used in the top hospitals. Care in the city owned hospitals costs as much as care in the private hospitals, but it is not as good. The reason is simple. The people working in the system view the care as subsidized care for the poor. I believe that many in the VA system share the view that they are serving a secondary population, in part because the veterans who have the resources are more likely to obtain their care through the private health care system.

There is no such thing as separate but equal. In my mind, I hope that universal coverage insurance ultimately replaces VA care, Medicaid, and Medicare. There may be differences in the level of coverage, with members of the military receiving more comprehensive coverage than provided in the "minimum" qualified plan, but the subsidies should be available to allow all people the ability to select the plan they want. There is no reason that care providers should know if coverage is paid through a public subsidy, or by Exxon Mobil. That will help eliminate some of the inherent stigma that is attached to public care programs now so that poor people and Veterans receive the quality of care that is being paid for.

[Gerry Clinchy]

Jeff, I did not mention at all about quality of care. I don't have the info to make a jugment.

What I was pointing out was the govt's lack of ability to "police" the VA system administratively. If they are not good at doing that for a much smaller system than the new one proposed, they are not yet suited to be effective on a much larger scale with more bureaucracy to monitor for fraud and abuse.

Since you mention that separate is not equal ... it occurs to me that even with universal care, those who have more $ will still be able to get better care either through better insurance coverage or through private payment.

According to the proposed plans, a certain "basic" plan will be required for all. That does not mean that everyone will get equal benefits. A long-term illness requiring $10,000/year in deductibles could still bankrupt a mid-income family. Might take a couple of more years to do it.

We will always have separation based on economic levels unless we decide to redistribute the income universally. It appears, however, that even in socialistic or communistic societies, there are those who live with more amenities, luxuries, etc. than the average citizen.

When China's bureaucrats are worried that its citizenry like capitalism a bit too much, there is something there to notice. (That info is only from a natural-born Chinese person now living in the U.S. but who continues to visit family in China.)

[YardleyLabs]

Jeff, I did not mention at all about quality of care. I don't have the info to make a jugment.

What I was pointing out was the govt's lack of ability to "police" the VA system administratively. If they are not good at doing that for a much smaller system than the new one proposed, they are not yet suited to be effective on a much larger scale with more bureaucracy to monitor for fraud and abuse.

Since you mention that separate is not equal ... it occurs to me that even with universal care, those who have more $ will still be able to get better care either through better insurance coverage or through private payment.

According to the proposed plans, a certain "basic" plan will be required for all. That does not mean that everyone will get equal benefits. A long-term illness requiring $10,000/year in deductibles could still bankrupt a mid-income family. Might take a couple of more years to do it.

We will always have separation based on economic levels unless we decide to redistribute the income universally. It appears, however, that even in socialistic or communistic societies, there are those who live with more amenities, luxuries, etc. than the average citizen.

When China's bureaucrats are worried that its citizenry like capitalism a bit too much, there is something there to notice. (That info is only from a natural-born Chinese person now living in the U.S. but who continues to visit family in China.)

The point is that under the proposed package, the government will not be providing health care to any more people than it does now. There is a big difference between providing health care and providing health insurance. Medicare has been providing health insurance very well for 40 years. What is effectively being proposed involves providing the equivalent of Medicare as a public option (except with more limited coverage than Medicare) as one option and privately run health insurance programs on the other. Everyone would be required to purchase some form of coverage meeting the minimum standards and people with limited means would receive a subsidy to help pay part of the cost of the coverage they choose. Where does that involve the government in providing health services? It seems to me that it has the private sector providing health insurance as they do now but with a larger population and certain restrictions such as not being able to cancel people arbitrarily if they are paying their premiums and not being able to exclude people for pre-existing conditions. The public option involves the government doing the same thing under the same restrictions as it does not in Medicare. We in trn get more choices about where we buy our coverage.

Now there are different ways that universal insurance could be provided and other ways that national health services could be provided. However, the way that the administration has proposed is very limited and relies almost entirely on the private sector for health insurance management and entirely on the private sector for health services delivery.

[Gerry Clinchy]

Once again, Jeff, care (or not care) the govt is not real good at controlling their bureaucracy ... and whether we're talking about universal health care or universal health care insurance, do we doubt that there will be lots of bureacracy involved?

Medicare has been providing health insurance very well for 40 years.

By "well" you would mean that it has taken 40 years to reach the verge of bankruptcy v. doing so in only 20 years? The bankruptcy thing, only what I heard in a speech by O. If they did it well, then it should be sustainable, shouldn't it?

I imagine that if Medicare did go bankrupt, if O didn't get this new health insurance program approved, he'd have heck to pay politically. If O believes Medicare is going bankrupt, and is pushing so hard for this more universal program, should he not have focused on making sure Medicare was fixed before the axe falls there? So, he gets his health stuff passed, and he is the hero of saving Medicare. 30 years from now, how do we fix the universal program when it gets in trouble?

BTW, those illegal immigrants. They could sink the boat. We know that O favored amnesty. Yup, McCain did, too, so I disagree with both of them. So, first he gets the health stuff passed, then moves onto getting the amnesty thing accomplished. Bait and switch, maybe? Add those illegals into the COB's calculations & I would expect that the cost #s will change quite a lot.

However, the way that the administration has proposed is very limited.

I don't think I'd term the proposal "very limited", but that is just a difference of perspectives.

and relies almost entirely on the private sector for health insurance management and entirely on the private sector for health services delivery.

But the govt will have a larger control over pricing. The results of this both through private insurors and Medicare is that providers raise their fees so that after the "powers that be" reduce them, they are still able to make their desired profit.

Perhaps what is really needed is to get real about the costs of procedures; or maybe it is the value in outcome-based payments, rather than fee for individual services.

I'd really like to hear what Dave, as a physician, could add to the discussion of the whole pricing thing since he has to deal with it first-hand.

[twall]

If the administration is truly serious about cutting health insurance/healthcare costs tort reform would be on the table. Defensive practicing of medicine adds greatly to the costs of healthcare. It results in many additional procedures and tests being performed. And, increases costs.

Compunding the problem of unecessary tests, and prescriptions, are the people who come in and demand this or that test or drug. Doctors try to educate. But, many get worn down and give up and order the tests and scripts. Putting up with some of the peoples behavior when they don't get their way is not worth the hassel. A downside of increased information is people coming in self-diagnosing and expecteing a care plan to match their diagnosis. If they don't get what they want/expect they feel they have the right to be verbally abusive to the physician.

Tom

[dnf777]

If the administration is truly serious about cutting health insurance/healthcare costs tort reform would be on the table. Defensive practicing of medicine adds greatly to the costs of healthcare. It results in many additional procedures and tests being performed. And, increases costs.

C
Tom

Amen!
And the true cost of defensive medicine is WAY higher than reported. The given numbers don't include things like time spent in depositions, time spent in legal planning committees, product liability costs to device manufacturers, documentation time costs.....just the added diagnostic tests alone are what we hear about, and that's just the tip of the iceberg. And it's all passed on to me and you, one way or another.

When I'm driving my GMC and a Bentley with plates "MEDMAL" passes me, it gets my hackles up.

[Gerry Clinchy]

This is from Fox News, so I expect there will be those that feel it is slanted. However, it does point to verifiable sources. I just don't have enough paper here to print out over 2000 pages of the bill & law to which the new bill refers. It IS a long read. But one would expect that given the complexity of the issue being covered.

Perhaps this is the problem with our legislative system. They write new bills based on definitions from existing laws; some of which may very well be at odds with the new proposals designed to correct "old" errors. I wonder if even the staff members who put the bill together for their bosses actually realize that the definition of "pre-existing conditions" has loopholes for both private and public plans?

This is one of the problems, I think, with O's lack of experience in Washington previous to becoming President. When he tells crowds that pre-existing conditions will be covered, does he have a full grasp of the definition that is being used in the law? Will there be surprises later because the loopholes haven't been attended to?

If we are destined to have a public option, they should at least get it right & solve the problems that such legislation is intended to solve. They've got a lot of things they can fix while they take the time to get this done well.

And now to find out what I need to do about Medicare, as it looms on the horizon for me shortly.

Here's the article:
Tommy De Seno - FOXNews.com - August 13, 2009
US President Barack Obama delivers remarks on the health care system at the annual meeting of the American Medical Association in Chicago, Illinois, June 15, 2009. REUTERS/Jonathan Ernst (UNITED STATES POLITICS HEALTH

[Gerry Clinchy]

cont'd


"You may have heard President Obama trumpet in many recent speeches his plan to have government run health insurance cover everyone's pre-existing medical conditions. As an example, he said to the American Medical Association on June 15, 2009:


"That is why we need to end the practice of denying coverage on the basis of pre-existing conditions. The days of cherry-picking who to cover and who to deny--those days are over."

That certainly sounds like signing up for one of the government insurance plans, no matter what ails you, will get you covered, doesn't it?


I was curious to see if the President is right about his plan putting an end to "cherry-picking" which illnesses to cover, so I decided to wade through the 1,018 page proposed health care law to find out if that's true.

Come with me on this fantastic voyage through a mess of cross-referenced and confusing legalese. As your tour guide, I have nearly 20 years experience in practicing insurance law, but reading this was not easy for me. We can get through it together though.

If the President wanted his health insurances to cover all pre-existing conditions, you'd expect some pretty simple language that says, "All pre-existing conditions will be covered." Take a look at what is written into the law instead:


Section 111 has this paragraph about pre-existing conditions:

A qualified health benefits plan may not impose any pre-existing condition exclusion...

Great! Looks like the President is telling the truth. Oh but wait, the paragraph doesn't end there. It continues...

... (as defined in section 2701(b)(1)(A) of the Public Health Service Act)...

Ok, that means we have to look up a whole other law - the Public Health Service Act (PHSA) - to find out what the definition "pre-exiting condition exclusion" is. But before we do that, the paragraph we are reading continues:

... or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent.

Ok, the paragraph we are reading has ended, but we now have two tasks: Go to the PHSA and look up the definition of "pre-existing condition" in section 2701(b)(1)(A) and the definition of "health status related factors" in section 2791(d)(9).

When we Google those sections of the PHSA to read it, we run into a problem: The section numbers referenced in Obama's bill for the PHSA are the old numbers. The PHSA has been amended with new numbers, so our Googling has failed us.

Undeterred, we print out the full text of the PHSA so we can read the whole thing and find the correct section numbers. Much to our chagrin, it is 1,476 pages long. There goes our Saturday. But we are committed to this project, so we bear down and find the right sections.

Here is how the PHSA defines "pre-existing condition exclusion" in section 2701(b)(1)(A):

IN GENERAL.-The term "preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.

That's great! I have to tell you, President Obama seems a man of his word...oh wait. We had two things to look up here in the PHSA, didn't we? Section 2701(d)(9) defines "Health Status-Related Factor" like this:

The term "health status-related factor" means any of the factors described in section 2702(a)(1).

Ok, what kind of dirty trick to waste our time was that? President Obama sends us to section 2701 for a definition, and the definition is"see section 2702." Why not send us right to section 2702? Sigh. Fine. Let's keep reading.

Section 2702 (a)(1) of the PHSA says:

(a) INELIGIBILITY TO ENROLL.-
(1) IN GENERAL.-Subject to paragraph (2),...

OK, stop right there. Just know that as we continue reading paragraph 1, we have to withhold any conclusion, because everything we are about to read is subject to paragraph 2. Ok? So let's continue with paragraph 1:

... a group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

A) Health status.
B) Medical condition (including both physical and mental illnesses).
C) Claims experience.
D) Receipt of health care.
E) Medical history.
F) Genetic information.
G) Evidence of insurability (including conditions arising out of acts of domestic violence)

H) Disability.

Well, I have to tell you up to this point President Obama is still looking good. Paragraph 1 seems to say the Government can't deny you coverage based upon any of the above pre-existing conditions. Oh but I forgot - the whole thing is "subject to paragraph 2." Let's see what that says:

2) NO APPLICATION TO BENEFITS OR EXCLUSIONS.-To the extent consistent with section 701,...

OK,, stop right there. They are making us work again. We are going to continue reading paragraph 2, but we have to withhold conclusions because we have to make sure it is "consistent with section 701." All right, here is paragraph 2:

paragraph (1) shall not be construed-
A) to require a group health plan, or group health insurance coverage, to provide particular benefits other than those provided under the terms of such plan or coverage, or
B) to prevent such a plan or coverage from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or overage for similarly situated individuals enrolled in the plan or coverage.

The bottom just fell out, and Obama is looking pale. The above language in paragraph 2 just put a whole bunch of power in the hands of the folks writing the policies when it comes to pre-existing conditions.


But before we analyze that, remember paragraph 2 has to be "consistent with section 701." So let's look at that. It says:

The purpose of this subpart is to enable the Secretary to provide a Federal program of student loan insurance for students in (and certain former students of) eligible institutions (as defined in section 719).

Wait ... what? What's that got to do with the price of tea in China? We are talking about pre-existing medical conditions and suddenly we get sent to a section about - I don't know - giving loans to foreign exchange students from Kenya?

I think I know what happened there. The Public Health Service Act was originally written in the 1940's and has been amended many times. Somewhere along the way Congress just got sloppy, and now there is a cross-reference that either makes no sense or the connection is so obscure even comedian Dennis Miller thinks it's a little far-fetched.

I think it's just a huge typographical error, so the only thing we can do is ignore section 701 and get back to paragraph 2 of Section 2702, which we were discussing above.

I know all of this is confusing, but let your trusty tour guide tell you where you stand:

What paragraph two says in part A is that policy writers for the government will be allowed to make the insurance you buy cover certain ailments, and not cover others (one of which may be a condition you happen to have, which is pre-existing).

What paragraph two says in part B is that policy writers for the government will be allowed to limit the amount, level, extent, or nature of the treatment you get for certain ailments (one of which may be your pre-existing condition).

So who will be writing your insurance policy? According to the President's plan, a new bureaucracy known as the "Health Benefits Advisory Committee." It will be made up of 27 people, and guess how many have to be a treating doctor: One.

So if you believe President Obama's quote to the AMA means that if you sign up for government insurance your pre-existing condition will automatically be covered, - you're wrong, and so is the President. You'd better read the fine print on whether the gang of 26 bureaucrats plus one doctor is going to cover your pre-existing condition or not. President Obama is giving them the power to not cover you.
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Seems like it would have been easier to write a new, clear definition of pre-existing condition and stipulate that it superceded and replaced definitions in previous legislation. Maybe they didn't realize the definition they were referencing? Worse, maybe they did.