Tag Archives: health care

The Elephant in the Room

Elephant in the roomWe’ve all heard the mind-numbing numbers:  $14 trillion of national debt that will grow to $20 trillion by 2010, but is it real?

Technically, and by the political definition, yes. It is the cumulative difference between actual revenues and spending. But by any reasonable accounting standard, our definition of national debt is hoax. More precisely, it is a political hoax within a hoax.

Almost two-thirds of the national debt is owed to us – mostly to our own government and its agencies. So when the pundits of doom talk about the impending explosion of interest on the national debt, one should smirk, a bit. We have systematically plundered Social Security, Civil Service and Military retirement funds (and other trusts) – like corporate America, we are never going to pay our pensions back, we’re going to change the rules. The Federal Reserve has purchased trillions of our national debt (quantitative easing) – in effect, it has already been paid by devaluing our currency. We have also allowed “banks” to go to the Fed money window for trillions of dollars at almost no cost that they have turned around and used to buy huge amounts of our debt making incredible profits – paying them back is little more than accounting.

Only about one-third of our national debt is owned by American and overseas investors. Were the Fed sponsored debt already paid with imaginary dollars subtracted from the $14 trillion, we owe far less than than the 76% to GDP ratio we hear so often. It would be more like 25% – an amount that would rank us among the most solvent countries in the world.

How did we get in this situation? You know. The Bush, now Obama, tax cuts for the rich when combined with the unfunded wars, the bailout of Wall Street and the stimulus bill, total almost all of it. To their credit, the Dems, in passing the “Affordable” Health Care Act and losing the mid-terms, will save a couple of trillion in the next decade, but we trillions on the table as bribes to health insurance companies and big pharma to get the bill passed. The surplus to debt happened in less than ten years. It could be undone in less than 151.

Except… for the non-debt debt – the elephant2 in the room – our unfunded liabilities. It would take, perhaps, $100 trillion to fully fund our pension and veterans obligations while continuing to fund Medicaid and other off-the-book obligations. A $38 billion cut, which almost forced a government shutdown, is stomping on ants while the elephants are jumping over the wall. Silly politics. Televised sport and nothing else. Look for the reruns to begin airing in a few days.

The only responsible way to address the real debt, is to get politicians out of our accounting and health care3. Treat Social Security, Disability and Medicare as tax financed programs – without a cap, not pretend trust funds. Require all tax cuts, breaks and subsidies have a sunset provision that forces a new and separate vote to continue. Stop treating earned and unearned income differently. Plug the loopholes. Send all corporate lobbyists to Guantanamo subject to military tribunals. Pass legislation limiting political contributions so they can only be made by individuals. Require competitive bidding for all government contracts. Give the states access to the Fed money window. Get out of the wars, slash the Pentagon, NSA/CIA budgets, require a two-thirds vote in Congress to wage war and support the UN to be the world’s peace keeper. Pass immigration reform to get the 20 million here undocumented, to pay legal taxes and Social Security and have access to better paying jobs. Create a Roosevelt-like works program that offers an alternative to long-term unemployment. Require two years of community or military service for our young people and offer college as a reward. Invest in a national system of medical clinics, private or public, to implement much of Medicaid. Do something. Don’t just cut something. The systems, political, economic and accounting, are unsustainable and broken.

 

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1 By going back to historically low top rates, getting the hell out of the wars, requiring those too big to succeed without taxpayer funds to fail and getting people back to work. Duh.
2 Yes, it is ironic that the elephant is the symbol of the GOP.
3 I know, I know, I know, you are thinking, what the hell does he want to go and write about this for? Ignorance is bliss. Leave it to Nobel prize winning economists and people running for office to make this stuff up. Just couldn’t help myself.

Boiled Frogs

A recipe for a very rich stew. Serves fewer than 1%.

Cooking Directions:
In a very large melting pot, add 200+or- million domestic and imported frogs, toads, tadpoles, pollywogs and porwigles. Do not preheat. Slowly, ever so slowly, raise the heat over 50 or 60 years.

While constantly stirring, gradually add

  • 4.5+or- % average annual inflation – make sure as much of the increase as possible comes from food, health care, prescriptions, insurance and energy costs, and as little as possible comes from wages;
  • 1+or- % average annual reduction in top marginal tax rates while flattening all tax rates;
  • Easy access to cheap credit – IMPORTANT: gradually reduce access while increasing rates and fees over cooking time – whenever possible, connect credit to home ownership and inflated appraisals;
  • Deregulated banking and securities industries;
  • Offshoring of industrial jobs – IMPORTANT: gradually reduce all anti-trust protection – for the best taste, remove all regulations and protections;
  • Heaping amounts of fear, race and class baiting, nationalism, chauvinism, religious intolerance, ignorance, scandal, distortion, misinformation, spin and Republicans.

During cooking, strain off any frogs that have grown large enough to feed Wall Street.

Just prior to serving, burst any bubbles, which might have formed in housing, stock market or pensions and remove any remaining safety net.

Season to taste with extended patent protection, subverting public utilities, tort “reform”, additional sales and sin taxes, lotto, industrial waste, carbon emissions, special tax breaks for business and the wealthy, criminalization of street drugs, and high fructose corn syrup.

Bon Appétit.

If you drop a frog in a pot of boiling water, it will of course frantically try to clamber out. But if you place it gently in a pot of tepid water and turn the heat on low, it will float there quite placidly. As the water gradually heats up, the frog will sink into a tranquil stupor, exactly like one of us in a hot bath, and before long, with a smile on its face, it will unresistingly allow itself to be boiled to death. – Wikipedia

Pledge to America: the cliff notes

The long awaited sequel to Newt Gingrich’s 1994 “Contract On America,” is out. Here are cliff notes. A summary of sorts inspired by Cliff Hillegrass’ original, but written for the lemmings expected to be led and fall from the cliff.

Overall:

Republicans pledge to reconnect with their version of the “permanent truth” of long-buried, rich, slave-owning white men – none of whom were Baptist – who lived in a time before indoor plumbing, electricity, automobiles, telephones, television, internets, rights for women or people of color, automatic weapons, predator drones, polling, political action committees, Republicans, Democrats, citizenship, elections, Wall Street, public libraries, credit cards, corporations, health insurance, retirement plans, banks, dollars, and the life expectancy was about 30.

Republicans pledged to offer a “plan,” rather than an “agenda.” They announced their firm patriotic pledge to be against uncertainty, red-tape factories specifically located in Washington, D.C. (other color tape factories and those red-tape factories in other areas are apparently just fine) and people not working. They reaffirmed their pledge to listen to the minority mob at this critical time when those elected by the majority don’t seem to be listening to Fox.

Based on the 50 photos in their 48 page pledge, they are also pro-cowboy hats and are really really pro-white people – only one person of color was shown, John Boehner who is orange.

Jobs, Jobs, Jobs:

They believe our economic problems are caused by heavy hands, a dead economist, and the continued cowardice of business owners. They believe the Democrat bill that provided the largest middle class tax cut in history, revenue sharing to the states to keep schools open and teachers and police on the job, and investments to rebuild roads and bridges that put construction workers back to work should have been cancelled.

They pledge to put people back to work by not spending money and definitely not hiring them by the government. They believe that it is critical to give people making so much money that they couldn’t find enough tax dodges and have to report over $250,000 in earned income a 3% tax break. They believe the Republican initiative to save Wall Street has caused investor uncertainty, but that if Wall Street has to obey the rules, they won’t take risks and our economy won’t trickle on middle class and poor people.

They pledge to end the deficit by permanently not raising taxes, giving more tax deductions to corporations, repealing the requirement for corporations to report expenses over $600, and requiring an act of Congress for almost any new business regulation. The Republicans pledge “put us a path to balance the budget and pay down the debt” by immediately cutting $100 billion from the stimulus bill that would have been used to buy American products and hire Americans to rebuild decaying public buildings and bridges. They pledge to go back to the Clinton-era, Obama-endorsed, pay-as-you-go strategy on new spending, except in the cases of unexpected emergency Republican spending such as highway funding, new subsidies for agriculture, more fighter jets built in Republican districts, etc. They also have pledged support of Obama’s plan to re-privatize Fannie Mae and Freddie Mac.

Healthcare:

They pledge to immediately repeal healthcare reform and replace it with common sense, allowing HSAs to be used for anything in a drug store, getting rid of state regulation of health insurance companies, and, of course, tort reform. No mention of the 50+ million Americans who don’t have health care coverage. They also pledge to discontinue the federal prohibition on abortion funding and replace it with a prohibition on abortion funding.

Government Reform:

The Republicans pledge a requirement that every law carry a Congressional version of a Bush signing statement – just a little something to clarify intent which can be used before the Supreme Court or campaign contributors. The idea is that regardless of whether the bill is constitutional, if they say it is, and the President signs it, they agree on intent, which should put the judiciary on proper unconstitutional notice not to disagree.

They pledge to require that all bills be posted 72 hours before a vote as the Democrats already do. The theory is that it will give Rush, Glenn and Sarah more time to alert the radio, cable and tweetisphere to alert the people to alert the pollsters to alert the staff to alert our leaders how to vote.

They pledge to require that at any point in the process, any legislator can offer an amendment to reduce spending and send the bill back to a committee to restart the never ending process which should, once and for all, mean that Congress will never pass another bill while a black man is in the White House. If that doesn’t work, they also pledge to make sure measures are passed “one at a time” rather than bundling a critically important-to-K-Street bill with other bills not considered important by Republicans. And if that doesn’t work, they also pledge to put an expiration date on all federal programs to coincide with election years including Social Security, Medicare, and Medicaid, but plan to save Social Security by cutting benefits until it is so unpopular that we won’t want it any longer.

They particularly are against big government, but pledge no specific size goals. They are also pro-accountability and transparency, which is code for, “we can’t wait to start the inquisition of Obama.”

Security:

Not much here. I suppose they got to their page limit. They pledge to pass a “Clean Troop Funding Bill,” I know it sounds as if the Republicans are anti-dirty troops, but they aren’t. The pledge is totally meaningless except to provide some cover should they fail on other pledges and have to pass a military funding bill that includes bridges to nowhere.

They also pledge to “demand an Overarching Detention Policy” to prevent those illegally detained by our government anywhere in the world, but especially those in Guantanamo, from having a fair trial, to fully fund the fully funded Star Wars missile defense shield, even though it is still illegal by treaty and will never work, but Reagan wanted it, and they reiterate their dislike for Iran and immigrants, but pledge no specifics of how they are going to make their lives worse.

Energy:

They pledge they are for domestic energy production and against cap and trade, but pledge no specifics and certainly didn’t pledge anything to address global climate change or new energy sources.

The complete 48 page Republican “Pledge to America” can be read here.

What would Pat Robertson say?

Goldman SucksLet’s take a quick look at recent legislative initiatives and the relationship of opposition-killing news events:

  • Health care reform – dead in the house and frozen in the senate until Anthem/Blue Cross announces billions in earnings along with huge policy price increases and the tea party takes the Kennedy senate seat.
  • Wall Street reform – seemingly dead in the Senate, then record-breaking Wall Street profits, revelations of sinister-sounding, but all too routine conflicts and manipulation, then Goldman Sachs was indicted.
  • Immigration reform – no one thought this could get a breath of political air during this partisan election season, then along comes Arizona’s xenophobic immigration law.
  • Energy bill – not a hope in hell for Senate action this year and, boom, BP/Transocean’s Gulf oil platform explodes, drill-baby-drill turns to spill-baby-spill and the oil-version of Katrina makes landfall.

Acts of god? A conspiracy of the non-working liberal press? Greed and hubris metastasizing naturally? Or, is Rahm, just that good?

We don't deserve them

What an amazing session. To watch and listen to the 10+ hour session and the debates, one could have a sense of how truly difficult it is for a bill to pass – much less anything as important, historic or intelligible. It is no wonder that it took more than one hundred years to pass a health care bill that will have such dramatic and direct impact on every American’s* life.

While the celebrity stars of the drama will get the appreciation (or vitriol) of the political junkies and news and opinion readers, I believe it is time to acknowledge those who do not – those long-suffering, unsung Congresspeople, so often scorned, forgotten and reelected.

It is truly amazing what they do for their measly $174,000 salary. To work so many late nights, Saturdays and Sundays. To endure the long hours of stifling boredom and suffer the almost unending pedantic speeches of their opponents waiting patiently for their yielded seconds in the spotlight to utter these memorable words, “I ask for unanimous consent to revise and extend my remarks in support (or opposition) to this flawed health bill” – strategically determining as they read the request whether to embellish it and have their side charged with a five-second penalty.**

Enduring the uncomfortable shoes and suits of the dress code, our elected leaders are always ready to gadfly their dear friends across the aisle, or rise to express their moral indignation (with hope it can be used in a future campaign spot) using the lexicon of today’s talking points in support or against whatever rule, motion or point of order – never forgetting to mention a poignant email or lesson learned from devoutly humble (Christian, hard working, common sense, heroic, victim, or folk wise) role models, which they hope will make them seem almost human and somehow connected to what is important to actual or imagined people, living or dead.

How they can even stand up under the extra weight of the devil of ready contributors representing special interests on one shoulder and the angel of protecting our democracy and representing what is best for the people on the other, is beyond my capacity to understand. I am humbled and grateful for the enormous weight of responsibility they bear for our country and those who pay for their campaigns.

To stay awake, seem sober, and maintain electable posture while not confusing the moments when they are to smile and the moments they are to seem serious (anyone remember when Lindsay Graham inadvertently clapped for President Obama during the State of the Union?); to sound thoughtful when parroting sound bites or attempting to clarify a complex issue for which they don’t have a clue what the question was about because it wasn’t in their prep; and stay cognizant of the momental seriousness of what is really going on, while never laughing inappropriately, relishing a moment of undeserved triumph unless on Fox or drawing attention to an opponents personal faux pas – they are special, no wonder so few would be up for their job.

To play their role in an unrehearsed stage drama recorded for history, always hitting their mark, in character, and delivering their lines with proper inflection while an aide is feeding the next words and names into their ear, a person of authority above them is threatening the gavel, and their fellow cast members forming a distracting queue for the next scene. Always ready to make a parliamentary inquiry into the arcane process in the archaic language to buy time or cover a false step.

They are amazing. No wonder America is so great. No wonder our founding fathers are so revered for designing this system. Speaking as one of their bastard spawn, I’d just like to say, thank you. You have made my life seem so sane and exciting compared to what you do for me.

Why do they do it for only $174,000? Must be the benefits. That, and I’m I just guessing, there are no other jobs that reward such talent.

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*There are 10-20 million people currently living in the United States who will not be impacted by this legislation – those who are here illegally or without documentation. You might recognize them in the emergency room during your next visit. This law codifies that these people (that includes their innocent children) who share our genome, our neighborhoods, our schools, our places of worship and our workplaces, will not be allowed to buy into insurance pools and have no right to affordable care while in the United States.

**By uttering these words, they are allowed to submit whatever they want to have said, should they have had the occasion to speak, into the official Congressional record. Should they add a word or two, such as “government takeover,” “baby-killing,” or “he’s not a citizen,” the extra time will be subtracted from their parties alloted debate time.

Health Care: When You'll Get Yours

Updated 3/19/201o to include the House Reconciliation Bill & CBO estimate.

The Democrats say it is going to pass – maybe this week. For those of you who haven’t had a chance to read all 2,009 pages (depending on which version you count) of the Senate’s Patient Protection and Affordable Care Act (AKA: HR 3590) and or even the 74 page summary – and, the 153 page House Reconciliation Act of 2010 (AKA: HR 4872), I thought you might like to know what’s in it for you. And when.

There are some really important things in the combined bill including, according to the CBO, covering an estimated 95% of our citizens – 32 million more than have insurance right now. It corrects many wrongs too long overlooked. It is a good start. Better than nothing, but miles short of wonderful. It isn’t a pretty read. It is filled with technical issues. Way too much of it is really about Medicare, Medicaid, tax policy and deals struck with vested interests (private and public interests) to get the bill passed. Way too little of it is about making health care affordable and keeping it that way for people in the middle who trying to stay there.

It is an improvement on the status quo. It will lay important groundwork for modernizing our system and making it more fair. It will reduce the deficit (while CBO estimates it will cost $940B over 10 years, it would yield a net reduction of our deficit of $138B and reduce it $1.2T over 20 years). It will save lives. And it will take years, as is typical, for it to be interpreted by our bureaucracy into policy and then by lawyers and accountants into loopholes. It is not – not even close to a government takeover – if anything, it is just the opposite – giving private industry yet another shot to heal itself.

What it may do best will also cause the most political damage to the courageous men and women who worked and vote for it: most of the bill is phased in over four years to minimize cost, allow for industry to prepare, and should it be necessary, to provide time for our politicians to fix obvious problems – but it will probably be too late to save those who will have to fall on the sword during the next election cycle for our future.

The clear winners include: seniors (prescription donut hole and no cost preventative care – note: more is expected to come from reconciliation); those over 55 being forced to accept early retirement; those disabled who need care and their families; the working poor and uninsured; all those under 26, students and especially children (OK, and their parents); small business (insurance choices and tax credits); the health insurance industry and providers (30+ million new paying customers – note: physicians and hospitals did not do as well as insurance and pharma, but I suspect, most will be relieved/happy for their patients); software developers, tech support, data managers, etc.; state governments (healthier citizens, few unfunded mandates and a dramatic reshaping of indigent care – note: reconciliation is expected to provide more help to the states on mandated Medicare changes); deficit hawks (saves taxpayer money and sets framework for future changes); and millions of patient advocates, volunteers, social workers, community health clinics and civic organizations who tirelessly help those less fortunate.

The losers: those making over $250,000 a year (.09% wage tax and 3.8% investment income tax, plus some minor changes in deductions) and especially senior health insurance executives or those with exotic medical and compensation plans; lawyers (fewer bankruptcies); and copier companies, copy paper producers and related products. Mostly the losers are those who can’t wait until 2014 – and probably the Democrats.

Was Going To Happen This Year No Matter What

  • Private health care insurance companies will immediately raise rates as high as possible – they would have whether the bill passed or not. Witness: Anthem of California’s rate hike of up to 39%. Get ready, if being ready helps. It will be ugly. There is almost nothing stopping them now or ever. They are bulletproof. A win-win-win. Without competition the market just can’t correct it, and what competition there will be, is years away.
  • Tens of thousands of employers will react to these rate hikes by either raising employee health care costs or quit providing coverage – they would have whether the bill passed or not. Good luck.
  • Millions of individuals will drop their coverage because they can’t afford it (the Robert Wood Johnson research puts the number expected to join the uninsured in the next 10 years at 18.2 million, bringing the total to 67.6 million without insurance) and play the American version of Russian Roulette betting they will survive long enough for the bill to phase in subsidies and benefits. Most would have dropped their coverage anyway. They will blame it on the economy, the private insurance companies and Washington. They should.
  • States, faced with insurmountable budget shortfalls, will cut reimbursement rates to doctors and hospitals, which will cause thousands of providers to drop Medicaid resulting in hundreds of thousands of people going without any health care (your neighbors will be among them), many of whom will die.
  • The midterm elections will be held before almost anything tangibly good in the bill changes anything. There may be hell to pay.
  • The next presidential election will be held before almost anything tangibly good in the bill changes anything, but after the taxes, fees and requirements go into effect. There may be hell to pay.

Immediate (within 90 days)

  • Those uninsured who have pre-existing conditions, will have access to a national high risk insurance pool (using private providers or via state high risk pools) with financial assistance (limits out-of-pocket costs for coverage through the pool to $5,950 for individuals and $11,900 for families annually – up to $5B in total subsidies). This is temporary and will be transitioned to exchanges in 2014.
  • Will bar preexisiting conditions on children’s coverage.
  • Will create a new reinsurance program to make coverage more affordable for early retirees (55+) – basically, a subsidy for employee-based plans to continue coverage by paying up to 80% of the cost until Medicare.
  • Gradually closes the Medicare prescription drug gap (Part D “Donut Hole”) until it is eliminated in 2020. Effected seniors will receive a $250 rebate in 2010.
  • Increases the adoption tax credit by $1,000 (begins in 2009) and extends them through 2011 (one of those unrelated to health care bones tossed to the anti-women’s right to choose lobby, before the Senate caved totally).
  • Small business (up to 35%) and small nonprofit tax credit (up to 25%) on employer’s contribution to health insurance for employees.
  • A two-year tax credit (2009 & 2010 – capped at $1B) to encourage investment in therapies that prevent, diagnose and treat acute and chronic diseases. This was an attempt to win support of doctors, hospitals and equipment manufacturers.
  • Tax relief for health professionals with state loan repayments – doesn’t affect you and me, but will give tax help to some physicians in underserved areas.
  • Provides funds to build new and expand existing community health centers, and expands funding for scholarships and loan repayments for primary care practitioners working in underserved areas – some of this is new money, most is refunding existing programs.
  • Expands low-interest student loan programs and scholarships for health students and professionals.
  • Excludes the value Indian tribal health benefits from gross income.
  • Requires creation of a web site that will identify affordable coverage by state, tax credits, and other information of interest to small business.
  • Requires another crackdown and more screening on fraud and waste.
  • Creates another council to promote health policies.
  • Provides money to Health & Human Services (HHS) to figure out and quantitatively measure just how wonderful this program is. Or isn’t.
  • Extends payment protections for rural providers who don’t do enough business to make it on their own, but help a lot of people who couldn’t get help otherwise.
  • Creates a private, non-profit institute to identify “national priorities” and compare the effectiveness of health treatments, which is an attempt to create political cover when facing lobbyists who don’t want their pet projects cut.
  • Finally allows states the option of covering parents and childless adults up to 133% of the poverty level (in some states, not typically Southern, it is felt that the poverty level is too low and their least fortunate citizens a more humane program).
  • Establishes standards and community assessments for new nonprofit hospitals which should give some political cover for local government when facing neighborhood activists in cahoots with real estate developers, bond companies, etc.
  • Gives Blue Cross a special tax deduction as long as this non-profit don’t profit by more than 15%, which was designed to get a couple of votes in the Senate. (Note: this will likely be removed in the reconciliation bill.)
  • Imposes a 10% tax on indoor tanning services because their lobby was not as effective as the cosmetic surgery lobby.
  • Codifies and clarifies economic substance doctrine and penalities (again, not health care, allowable, important).
  • Appropriates $500M a year (2010-2014) for the Community College and Career Training Grant program; creates mandatory funding of Pell Grants, funds College Access Challenge Grants and funding for Historically Black Colleges & Universities; and reforms student loans, limits interest rates and reduces income-based repayment amounts (again, not health care, allowable, important).

Six Months After Enactment (and Beginning with Your Insurance Plan Year)

  • Prohibits rescissions (practice of rescinding coverage when a person gets sick as a way to avoid covering costs) – we all should count down the days and hope we aren’t on the rescind list.
  • Eliminates lifetime and restricts “unreasonable” annual limits.
  • Requires first dollar coverage (generally, no deductible) for preventative care.
  • Allows dependent coverage until age 26.
  • Requires creation of an “effective” appeals process for coverage determination and claims and awards grants to states in order to establish consumer assistance programs in response to complaints (boy, that’s going to work in Georgia).

2011 (lower your expectations)

  • Provides a free, annual wellness visit and no-cost sharing preventive services for Medicare beneficiaries.
  • Begins a 50% discount on brand name drugs for seniors in the Medicare prescription drug gap (Part D “Donut Hole”).
  • Creates incentives for states to cover evidence-based preventative services without cost-sharing for Medicare beneficiaries.
  • Requires Medicare coverage of tobacco cessation services for pregnant women (I’m guessing that this isn’t limited to pregnant women over 65).
  • All health plans must file annual reports showing share of premiums going for care and, should their accountants really screw up, they must provide consumer rebates for excessive medical loss ratios.
  • Provides a 10% Medicare bonus payment to primary care physicians and general surgeons (which they would have done anyway so that they don’t have to actually raise reimbursement rates – permanently raising would make it look as if Medicare was in trouble).
  • Establishes a “Center for Medicare & Medicaid Innovation,” which will attempt to create methods to reduce costs while enhancing care and which sounds like such a great idea, but makes every cynic snicker.
  • Provide several important policy changes related to education slots to increase doctors, nurses and care providers, but they are so tediously complicated I suggest you Bing or Google for the details).
  • Ditto on tax code changes related to standard language, small business cafeteria plans and other technical issues which would only pain you to know at this point, unless you are planning to raid your HSA, which you’d better do before the end of 2010. Oh yeah, your W-2’s will now show the value of your health benefit.
  • Begins the transition away from Medicare Advantage – that famously popular program where we, the taxpayers, give insurance companies 15% more to privately manage Medicare which they used to expand benefits by charging recipients even more. Wonderfully conceived experiment.
  • Imposes a non-deductible $2.3B fee (split based on market share) on big pharma in return for “supporting” this bill and our government agreeing not to negotiate prices or re-import drugs for Medicare or Medicaid which would, of course, bring prices way down for individuals who will have to wait four years to see benefit.

October 1, 2011

  • Allows states to offer home and community based services rather than institutional care to disabled individuals through Medicaid.

2012 (lower your expectations even more)

  • Implement payment reforms to gain efficiencies and improve quality.
  • Incentivize quality hospital outcomes and penalize hospitals with the highest readmission rates.

2013 (chances are, this won’t be your year either)

  • Begin paying Medicare physicians based on value instead of volume to promote quality of care.
  • Requires that Medicaid payment rates for primary care services be no less than 100% of the Medicare rates.
  • Mandatory adoption of electronic filing and information exchange (expect everyone to miss that deadline) and establish a pilot program of payment bundling and provider cooperation/coordination designed to save money, and, of course, improve care.
  • Increase the itemize deduction threshold for medical expenses from 7.5% to 10% of adjusted gross income for eligibility.
  • Add a .09% hospital insurance wage tax and a 3.8% investment tax on people making more than $200,000 individuals/$250,000 family.
  • Limits the deductibility of executive (all officers, employees, board members and contract workers) compensation of insurance companies to $500,000 each per year.
  • Sets $2,500 cap on over-the-counter medications for flexible spending accounts (FSAs).
  • Creates excise tax on medical device manufacturers of 2.9% (exempts Class I medical devices, eyeglasses, contact lenses, hearing aids, and any device of a type that is generally purchased by the public at retail for individual use) to raise $2B ($3B in 2012 and beyond).

2014 (finally and outrageous to believe that some of these weren’t done in year one)

  • Insurance companies are prohibited from discriminating based on health status, preexisting conditions, and gender. They still will be able to discriminate based on age, geography, family size and tobacco use, but they are limited to discriminating on rates of no more than three times their lowest rate.
  • Annual limits are eliminated.
  • Insurance companies will be prohibited from dropping coverage of those participating in a clinical trial or denying coverage for routine care.
  • Health exchanges are established in each state (yes, state) to enable people to comparison shop, enroll and determine if tax credits for financial assistance will be available.
  • A multi-state option (really national) will be available offered by private insurance companies and, at least one non-profit.
  • Health care premium tax credits will be available for those above Medicaid eligibility and below 400% of the poverty line (currently $43,320 for individual; $88,200 for a family of four – Alaska and Hawaii are higher). These credits will be for premium and cost sharing expenses and is what will enable most of the uninsured to afford coverage. What does all of this mean? If your income is above the poverty line, but less than 133%, you’ll have to pay 2% of the cost and the tax credit will pay 98%. The scale slides up to 400% of the poverty line and indexed year to year, but basically your share would be: 133% up to 150% – 3.0%; 150% up to 200% – 4.0%; 200% up to 250% – 6.3%; 250% up to 300% – 8.05%; 300% up to 400% – 9.5%.
  • Almost everyone is required to have health insurance or pay a penalty (2014: $95; 2015: $325; 2016: $695 or 2% (increasing to 2.5% in 2016) of income up to national average cap). Families will pay half the amount for children. The only exception is if affordable insurance is not available. Sounds onerous, but they are doing this because it wouldn’t be fair to the insurance companies for an individual to purposely not have insurance, get sick knowing they can get coverage by buying a policy only when they need it – plus, they made a deal with the insurance companies to do this in return for insurance companies agreeing to pay a fee to help offset the costs of the bills.
  • No one receiving a tax credit to buy insurance would be allowed to use it for a policy with abortion coverage. States can ban abortion coverage in plans offered through the exchange. Exceptions would be made cases of rape, incest and danger to the life of the mother.
  • Employers are not required to provide coverage. However, employers with 50+ employees (companies with fewer than 50 employees are except), who do not offer coverage, and have workers who are subsidized by the government, must pay a fee to subsidize those workers – $2,000 annually for each full-time employee (there is no penalty for the first 30 employees, plus, there are a few other caveats based on waiting periods, etc. Bing it). Part-time workers are included in the calculations (two part-time workers equals one full-time worker).
  • The small business tax credit will continue.
  • Workers who qualify for an affordability exemption to the requirement to have coverage, but not for tax credits, can take their employer contribution and join an exchange plan.
  • Medicaid eligibility will increase to 133% of poverty. Childless adults will be included for the first time. For new enrollees, the federal government share will be 100% in 2014, 2015, and 2016; 95% in 2017; 94% in 2018; 93% in 2019; and 90% thereafter (funding the state mandate).
  • Medicare advantage will be eliminated by competitive bidding.
  • Impose fees providers (health insurance companies): $2B ($8B in 2014; $11.3B in 2015 & 2016; $13.9B 2017 and $14.3B after that).
  • There will be more reporting requirements for many providers to measure quality of care as a pathway toward value-based purchasing.

2018

  • Impose the Cadillac excise tax of 40% on employee plans costing more than $10,200 for individuals and $29,327 for families of four (indexed for high cost states, high risk professions and for the elderly).

2020

  • Medicare Part D (prescription drug plan) increases to a 75% discount on brand name drugs for seniors and completely eliminates the “Donut Hole.”

That’s it. Hard to believe, isn’t it? Seemingly, our entire government has spent a year developing that? Every news channel, newspaper and most blogs have spent a year reporting and debating that? Republicans could spin endlessly for a year that this, often in the same sentence, would turn us into Nazi Germany or Stalin’s Russia? Hundreds of millions spent lobbying against that? Democrats could trade all the hope and power that comes once in a generation, for this? Yes.

If it weren’t passed now, we’d just have to go through this again some day not soon enough.

___________

Acknowledgements:
Information, reference and documents used in this story include those from:

And others too numerous to mention. Thank you.

Please don't throw me into the briar patch

please don't throw me into the briar patchLast night, Senate Majority Leader, Harry Reid announced a compromise health care reform bill with just enough public option that looks like it will pass – Olympia Snowe and Susan Collins are on board.

“I’ve got you this time, Brer Rabbit,” said Brer Fox, jumping up and shaking off the dust. “You’ve sassed me for the very last time. Now I wonder what I should do with you?”

Brer Rabbit’s eyes got very large. “Oh please Brer Fox, whatever you do, please don’t throw me into the briar patch.”

Private insurance didn’t cave. They loooooove what the Senate is now proposing. Sure, Brer Reid and his fellow Senate foxes probably think they got the better of the private insurance lobby last night…

“The briar patch, eh?” said Brer Fox. “What a wonderful idea! You’ll be torn into little pieces!”

Stop for a moment and think about it. The compromise proposal appears to give an option to those 55 and older to pay a premium and buy-in to Medicare – theoretically, at no cost to taxpayers. Sure, it is a government option. Sure, it may grease the path to an eventual single payer system. But my god, look at what it will do for the private insurance companies: it will move the most expensive customers they have off their books. Those very customers who have so many of the expensive pre-existing conditions. Those customers who take expensive medicines to reduce cholesterol, lower blood pressure and extend their lives. A virtual bonanza that will turn their premium amortization tables upside down.

“Drown me! Roast me! Hang me! Do whatever you please,” said Brer Rabbit. “Only please, Brer Fox, please don’t throw me into the briar patch.”

The Senate compromise proposal will likely carry a trigger – if the private insurance companies don’t hold premium costs down, there is a threat of a public option for everyone. No problem. Without the 55 plus-ers, insurance costs per policy will reduce dramatically (younger policy holders don’t cost nearly as much to insure), making the trigger an empty threat.

Grabbing up the tar-covered rabbit, Brer Fox swung him around and around and then flung him head over heels into the briar patch. Brer Rabbit let out such a scream as he fell that all of Brer Fox’s fur stood straight up. Brer Rabbit fell into the briar bushes with a crash and a mighty thump. Then there was silence.I was bred and born in the briar patch

Wait, you say, they will have fewer policyholders, won’t that increase the costs? That is not the way this briar patch is being grown. Both the House and the Senate bill will require everyone to buy insurance – private insurance – and provide taxpayer subsidies for those making up to 4 times the poverty level to do so. Instantly, the insurance companies will get 30 to 40 million new and cheaper customers paying full premium rates and will be singing the Song of the South.

Then Brer Fox heard someone calling his name. He turned around and looked up the hill. Brer Rabbit was sitting on a log combing the tar out of his fur with a wood chip and looking smug.

“I was bred and born in the briar patch, Brer Fox,” he called. “Born and bred in the briar patch.”

And Brer Rabbit skipped away as merry as a cricket while Brer Fox ground his teeth in rage and went home.

Click here to read the Remus tale