Wednesday, August 12, 2009

Is it Possible to Quell Health Care Reform "Outrage" With Facts? Let's Try...

I just can not get over the "outrage" of some people over the health care legislation. Now, before everyone gets upset that I'm lumping everyone with an objection in with the crazies, let it be said that I have my own questions and misgivings about the proposals in the first draft of legislation in H.R. 3200. Yet, that does not excuse the travesty that some people have reduced the political debate to. Partisan behavior is nothing new, but in the last six months, it has ratcheted itself up to a fervor not seen in years. The level of misinformation is infuriating for someone who wants the truth about the proposal, not to mention anyone with loved ones employed in the health industry.

The questions raised in the debate are myriad: Is this an attempt to incorporate a single-payer system similar to Canada's or the U.K.'s? Is this a viable option to private insurance? How will this impact Medicare? Will there be rationing of care? What is meant by the end of life counseling (on a side note: How much of an idiot is Sarah Palin for suggesting they would be "death panels"?)? How will this be paid for without a tax hike for the middle class? Will this put private insurance companies out of business? Unfortunately, the answers to these questions were sparse if available at all. So the purpose of this post is to report my best efforts for findings in regard to these questions, among others.

Possibly most important: Is healthcare reform necessary?

  • In my opinion, to put it simply, yes. Between 1999 and 2008, employer-sponsored health insurance premiums have more than doubled in the last nine years, a rate four times faster than cumulative wage increases. Whatever pay increases the average worker did receive were summarily wiped out, and then some, by the rapidly growing amounts deducted from their paycheck to cover their health insurance premium. The profits of insurance companies are sickening (pun intended) when compared to the rising burden placed upon the average worker. Nearly half of all personal bankruptcies are at least partly the result of medical expenses. Not only is there the problem of the 40+ million Americans without health insurance, but 86.7 million Americans were uninsured at some point in 2006 and 2007. In addition, the sheer numbers would dictate that something should be done in order to make health insurance, in some form, available to more Americans who desire it.
  • Not only is healthcare not financially feasable for a staggering amount of Americans, the Americans who do have health insurance are in constant danger of being dropped for the horrible sin of getting sick. Supposed "pre-existing conditions" are all too common in denial of care through a process known as Rescission. Rescission (also known as "post-claims underwriting") is the process whereby health insurers avoid paying out benefits to treat cancer and other serious illnesses by seeking and often finding errors in the policyholder's paperwork that can justify canceling the policy. In one job evaluation, the health insurer WellPoint actually scored a director of group underwriting on a scale of 1 to 5 based on the dollar amount she had managed to deny through rescission. (The director had saved the company nearly $10 million, earning a score of 3. WellPoint's president, Brian A. Sassi, insists this is not routine company practice.) Rescission's victims tend typically to be less-educated people who are more likely to make an error in filling out their insurance forms and lack the means to challenge a rescission in court—a path in which success is, at any rate, not guaranteed, because under state law the practice is perfectly legal if done within the allowable time frame (typically up to two years after a policy is issued).
Is this a single-payer system?
  • Once again, simply no. The UK has a single-payer system, the single-payer being the government. The proposal by the White House that has the most support in Congress suggests a public option run as a not-for-profit alternative in a insurance marketplace similar to the exchange offered to government employees. As proposed, the public plan would be one that competes on a level playing field with private insurers. Such an entity wouldn't be able to use its sheer size to set prices the way Medicare does--but it could nonetheless incur savings, and in so doing drive down the cost of health insurance in the private market. Critics claim that this would cut into the profits of private insurers and force them out of business in lieu of the competition, yet my response would be: isn't that capitalism at its best? In my opinion this would finally be the government interceding on the public's behalf, unlike in the banking fiasco.
Will we be cutting money from Medicare?
  • Yes, but not exactly in the way that the attackers are insinuating. The biggest part of the money proposed to be cut from Medicare would be the subsidies paid to private insurers for the Medicare Advantage (MA) program. The MA program, which pays private insurance companies a set rate to treat Medicare beneficiaries who sign up, it was conceived as a cost containment measure on the theory that competition between HMOs, PPOs and other private plans would drive down costs. In fact, MA plans have consistently cost the government more per beneficiary than traditional fee-for-service Medicare costs. About 18 percent of beneficiaries now belong to MA plans. The Congressional Budget Office estimates that if the government refused to pay MA plans more than traditional Medicare costs, that the taxpayers would save $9.5-billion in 2009, $54-billion over the 2009-2012 period, and $150-billion over 10 years. The $150 billion over the next ten years would be the most major of the proposed cuts. Other cuts are vague at best and labeled mostly as cutting inefficiency.
How would this be paid for?
  • Here the information is unclear at best. Obama has been adamant that he will not sign any legislation that adds to the deficit. The Medicare savings are a supposed large part of the estimated $1.5 trillion pricetag over the next ten years (less than the $1.8 trillion the Bush tax cuts cost us over roughly the same time frame), but it is not all of it. Taxing the upper classes charitable donations has fallen by the wayside, yet a proposal to limit the amount of deductions available to individuals making over $250,000 per year has been discussed as well as a surtax of 1%-5% on families making over $350,000.
  • Another option being considered is to tax employer health benefits. Right now, employees get all their health benefits tax-free—a policy called the employer tax exclusion. Althought this has bipartisan appeal, there are problems with this setup. For one thing, it is regressive as people with jobs are generally wealthier than those without, yet they get the tax break. It also reduces transparency, since employees don't know exactly what their premiums are paying for. In addition, it gives employers an incentive to offer high-cost health care plans, which don't get taxed, instead of higher wages. This proposal would cap the amount of untaxed benefits at somewhere around $12,000 or by income level. That would reduce or eliminate the preferential treatment described above. The government would collect an estimated $200 billion to $300 billion a year. Over 10 years, that's potentially more than $2.5 trillion, $1 trillion more than the government is estimated to need to pay for health care reform. Republicans and moderate Democrats have been pushing this idea for a while. Sen. Max Baucus included it in his original white paper on health care reform. Sen. John McCain made it the centerpiece of his campaign health care plan. The downside for Obama is that he adamantly opposed this policy during the campaign. Yet budget director Peter Orszag has refused to take the option off the table, and economic adviser Jason Furman has supported the policy in the past. Obama himself has signaled that he would allow it—but he doesn't necessarily want to propose it for obvious reasons.
What the hell is Sarah Palin talking about? (a.k.a. Will there be care rationing?)
  • Sarah Palin, the former governor of Alaska, urged her supporters to oppose Democratic plans for health care reform on her Facebook page. "As more Americans delve into the disturbing details of the nationalized health care plan that the current administration is rushing through Congress, our collective jaw is dropping, and we’re saying not just no, but hell no!" wrote Palin in a note posted Aug. 7, 2009. She said that the Democrats plan to reduce health care costs by simply refusing to pay for care. "And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care. Such a system is downright evil." For once, I agree with the quitter, that would be evil, too bad for her that is not what is being discussed. The truth is that the health bill allows Medicare, for the first time, to pay for doctors' appointments for patients to discuss living wills and other end-of-life issues with their physicians. These types of appointments are completely optional, and AARP supports the measure. Palin also may have also jumped to conclusions about the Obama administration's efforts to promote comparative effectiveness research. Such research has nothing to do with evaluating patients for "worthiness." Rather, comparative effectiveness research finds out which treatments work better than others. The health reform bill being considered in the House of Representatives says that a Comparative Effectiveness Research Center shall "conduct, support, and synthesize research" that looks at "outcomes, effectiveness, and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically." The idea here, which Obama and his budget director Peter Orszag have discussed many times, is to make it easier for doctors, health care workers, insurance companies and patients to find out which treatments are the most effective, as determined by clinical studies and other research. I looked for proof for the inflammatory claims that the health care bill encourages euthanasia. It doesn't. There's certainly no "death board" that determines the worthiness of individuals to receive care. She said that the Democratic plan will ration care and "my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care." Palin's statement sounds more like a science fiction movie than part of an actual bill before Congress. Obama has said he believes a comparative effectiveness commission should advise health care workers, not require them to follow certain treatments.
  • On the radio show of former Sen. Fred Thompson on July 16, 2009, McCaughey said "Congress would make it mandatory — absolutely require — that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner." She said those sessions would help the elderly learn how to "decline nutrition, how to decline being hydrated, how to go in to hospice care ... all to do what's in society's best interest or in your family's best interest and cut your life short." In her chat with Thompson, McCaughey said the language can be found on page 425 of the health care bill, so I looked there. Indeed, Sec. 1233 of the bill, labeled "Advance Care Planning Consultation" details how the bill would, for the first time, require Medicare to cover the cost of end-of-life counseling sessions. According to the bill, "such consultation shall include the following: An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to; an explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses; an explanation by the practitioner of the role and responsibilities of a health care proxy." Medicare will cover one session every five years, the legislation states. If a patient becomes very ill in the interim, Medicare will cover additional sessions. Jon Keyserling, general counsel and vice president of public policy for the National Hospice and Palliative Care Organization, which supports the provision, said the bill doesn't encourage seniors to end their lives, it just allows some important counseling for decisions that take time and consideration. "These are very serious conversations," he said. "It needs to be an informative conversation from the medical side and it needs to be thought about carefully by the patient and their families." In no way would these sessions be designed to encourage patients to end their lives, said Jim Dau, national spokeman for AARP, a group that represents people over 50 that has lobbied in support of the advanced planning provision. McCaughey's comments are "not just wrong, they are cruel," said Dau. "We want to make sure people are making the right decision. If some one wants to take every life-saving measure, that's their call. Others will decide it's not worth going through this trauma just for themselves and their families, and that's their decision, too." Both Keyserling and Dau were particularly troubled that McCaughey insisted — three times, to be exact — that the sessions would be mandatory, which they are not. For his part, Keyserling said he and outside counsel read the language carefully to make sure that was not the case. "Neither of us can come to the conclusion that it's mandatory." he said. "This new consultation is just like all in Medicare: it's voluntary." "The only thing mandatory is that Medicare will have to pay for the counseling," said Dau. There's really no gray area here. McCaughey incorrectly states that the bill would require Medicare patients to have these counseling sessions and she is suggesting that the government is somehow trying to interfere with a very personal decision. And her claim that the sessions would "tell [seniors] how to end their life sooner" is an outright distortion. Rather, the sessions are an option for elderly patients who want to learn more about living wills, health care proxies and other forms of end-of-life planning. McCaughey isn't just wrong, she's spreading a ridiculous falsehood.
Will there be rationing of care?
  • No. Mr. Obama said he was not proposing to ration care, but just wanted to coordinate it better. For example, he said, he wants to eliminate repetitious tests ordered by different doctors for the same patient. Electronic medical records and health information technology, championed by Mr. Obama, could reduce such duplication. But, under his plan, it is not clear who would take responsibility for patients and coordinate care in traditional fee-for-service medicine. President Obama has stated that rationing care is more rampant under our current system than it would be under the reform.
Sorry for the lack of exposition towards the end, this has been a rough post to research with a crabby three month old around. Any requests for further research or talking points are welcome, just post in the comments.

For the record, I do support health care reform. I would like a single-payer system, yet a public option would be a welcome compromise. Politics are compromise, maybe America needs to remember that instead of thinking that helping each other is somehow infringing on personal liberty. The thing that I keep in mind, and I hope you do too, is there is no actual bill yet. There are four proposals, with H.R. 3200 being the most complete (yet not the best by any stretch, the best in my opinion is the Wyden-Bennett Act). There is debate for a reason, to air all points and reach a consensus, not to shout each other down for having different beliefs, I don't agree with that tactic from the left or the right. That my friends, is not America, no matter what Founding Father you attempt to quote.

1 comment:

Brandy said...

Good thoughts. =)

Thanks for the follow via Twitter!