Tag Archives: medicaid

Bring Back the Bad Old Days

Bipartisan Congressional leadership meetingOh, how I long for the time when politicians lied to get elected. When a Democrat could run as a hawk and govern as a dove. When a Republican would run as a conservative and it meant they were cautious to change and represented traditional values, not the values of a mob. Oh, for the days when we knew the contract with America was not worth the paper it was printed on.

When getting things done was the goal of both parties and compromise was seen as a victory for each. Incrementalism was the result. Respect was the rule, not the exception. Peace was a goal. Being patriotic included doing what was best for all Americans. Believing in Democracy included supporting majority rule. Laws were meant to protect people. Justice was non-partisan. Giving a leg up to someone less fortunate was an ideal. Educating our young and taking care of the aged were bi-partisan platforms. Delivering jobs in your district was a good thing, because it meant jobs. A time when campaign promises were quickly forgotten to be replaced with the reality of American life. And flip-flops were what you wore on the beach.

Oh, how I long for the time before entertainment news. Before celebrity politicians, pundits and talking points. When extremists didn’t get air time. When politics was dull and before it became a made for TV sport with avid fans* on both sides.

It was Dick Cheney, who said in 2002, “Reagan proved that deficits don’t matter.” It was also Reagan, who proved that raising the debt limit doesn’t  matter – he raised it 17 times in his eight year mythological reign. Bush, Jr. raised it seven times. But now, Obama is President, so it does matter.

It matters, because to win as a Republican, you must, no matter what:

  1. Keep a promise to Grover Norquist never to vote for any additional government revenues, including, but not limited to taxes, fees or ending subsidies;
  2. Keep a promise to the Tea Party to reduce the size of government** and the reach of government regulation;
  3. And keep a promise to Republicans everywhere to defeat President Obama.

Passing a debt limit extension, which has been done 74 times since the law that required it was passed in 1962, may violate promise number three: to defeat President Obama, no matter what.

President Obama did not cause this problem. In fact, he has done more than any President in two generations to help the Republicans keep their promises. Federal, state and local taxes are the lowest per capita since 1955 – well below the high water days of Nixon and Reagan. It is a fact that President Obama has presided over cutting taxes more than any President in history.

But Obama’s help to the Republicans doesn’t stop there. He has secured the Republican promise to reduce the size of government – the number of government workers has gone down by 500,000 since Obama took office.

What more must he do? For the answer, just look back to April when the House Republicans voted to privatize Medicare and increase the costs to seniors an average of $6,000 a year (not a tax). The House Republicans also voted to turn Medicaid, the medical safety net for the poor and disabled, into a voucher system so the states could make Medicaid meaningless (not a tax). Immediately after their votes, House Republicans poll numbers fell off a cliff. They have only one chance to save themselves: force Democrats into drinking the poison tea, too.

Now, we are being held hostage to a crisis totally of Republican promise making – a demand that any agreement to raise the debt limit be matched by permanent spending cuts and include entitlements (not a tax). At least two trillion in additional debt is needed to fund authorized spending through the next election.

Obama, true to his campaign promises saw this as an opportunity to enroll the Republicans to do something meaningful. Why not take the advice of Simpson-Bowles? Cut four to six trillion of the debt by a fair combination of revenue increases and cuts to discretionary and entitlement spending. Nasty compromises required for both parties for the good of the nation to secure our future. No new taxes would be included – just plugging of corporate loopholes, ending of subsidies for corporations who don’t need them, and allowing the Bush tax cuts to finally expire. To protect the fragile economy, neither the revenue enhancement, nor the spending cuts would be immediate. Nor would the entitlement changes privatize Social Security, Medicare or Medicaid — more likely, a means test, and some reimbursement and cost of living changes.

Too bad for all of us. To keep their campaign promises, Republicans won’t do the big deal and may not do any deal. Republicans were gamed last spring by Obama in the continuing resolution deal. The $30-40 billion in cuts turned out to be only a few hundred million – maybe less. Republicans don’t trust Obama – he’s considered too smart for them.

Who will blink and when? The White House told seniors today that they may not get their August 3rd Social Security checks. The pundits are camped in the cable network parking lots. The rhetoric talking points sound as if both sides are going to the mattresses. This is going to be close.

Without an agreement, the Republicans are likely to pass something partisan in the House. Depending on the details, and they are likely to be onerous, it is doubtful that it could even come to the floor of the Senate.

Thursday, Senate Republican leader Mitch McConnell has suggested a back up plan that would give the President new power and release Republicans from having to vote for anything that they have promised not to vote for. Lending authority for the balance of this Presidential term would be granted in three installments of up to $2.4 trillion, provided that the President cut spending by the same amount. Congress’ role would be reduced under special rules such that they would only be able to vote against a Presidential plan. Which of course, Republicans would. Which would then be vetoed by the President. The McConnell plan would give Republicans 100% authority to blame Obama for all of the economic woes, while keeping their agenda of fear in the news, and keep moving the day the world ends as we know it until just before the 2012 election. This plan, is likely a non-starter, as it would be giving the President way more power than Tea Partiers’ are likely to approve in the House.

Scenarios for default are unprecedented and no one really knows how one would play out. The White House may not have the authority to prioritize spending – allowing them to default on some debt to make payroll and pay other bills. At this time, the White House doesn’t plan to use the 14th Amendment, but may anyway. The Supreme Court will surely be called to decide many emergency details.

Should a deal not be done, what happens next is almost too dark to describe — sounding more like apocalyptic fiction than what is so seriously possible.

Inaction by Congress before recessing on August 5th would mean that revenues would only be available to pay 40-45% of our bills (that is 10% of our economy that would be missing in August). Our debt would be downgraded by ratings agencies. Smart money would likely already have made their bets — shorting everything — especially instruments guaranteed by our government — and almost guaranteeing things will get worse quickly. Safe places for cash would be almost impossible to find. The market impact of would be immediate. Everything will begin to go down. At 1000 Dow points down, margins calls will become commonplace forcing the markets lower and increasing computer trading.

The Treasury would be called to make hard and unpopular choices on who to pay with the estimated $172.4 billion of August revenue. Non-essential government workers would be sent home. The parks would close and campers evicted. Payments for Social Security, disability, VA benefits, food stamps, unemployment benefits, Medicaid and Medicare reimbursements, rental assistance, public housing funding, children nutrition programs, Pell grants, state education grants, IRS refunds, military active duty pay, federal employment salaries and others would be at risk. As would contracts for defense, Homeland Security and others.

“Handling allpayments for important and popular programs (e.g., Social Security, Medicare, Medicaid, Defense, active duty pay) will quickly become impossible.” – Bipartisan Policy Center

Here are examples of some of the choices we would have in August from the Bipartisan Policy Center:

Payment scenarious from the Bipartisan Policy Center

Payment scenarious from the Bipartisan Policy Center

The Treasury must also rollover $507.4 billion in debt in August and there may be no takers – interest rates could skyrocket increasing the national debt even more, while reducing funds available to pay bills — and the Fed may have to intervene. Home sales would stop. As markets and currencies tank, people, banks and countries would begin to fail. There will be chaos on all world exchanges and many would be shut down. People would take to the streets. Then it gets really bad.

Even if Congress passes a bill by mid-August, there is great risk that the damage to markets and interest rates would already be so great that we would be thrown back into a deep recession.

More money could be lost in the markets during the first week than is needed for the debt increase. More money could be lost in the subsequent weeks than our national debt. Recession could easily turn into depression. People would jump out of windows. War might be threatened. All because of campaign promises. Oh, how I long for the time when politicians lied to get elected.
________

* Short for fanatics.
** Officially, the Pentagon, CIA, NSA, etc. are not included.

_________

Editor’s note: The post was updated at 7:43 am on July 13, 2011 to correct and provide new details of the Mitch McConnell back up plan as they became available.

Winning No Matter What

The public strategy seems straightforward – the minority party holds the national debt hostage in an attempt to force the majority party to voluntarily undo three generations of their own progressive policy. On face value, it seems brilliant.

The Republicans, after all, are largely responsible for deficit and the worst depression since Prozac. When they took power under Bush, there was a $235 billion surplus. When Bush left office, the national debt stood at $10.6 trillion and deficits, based on Bush/Republican approved spending, were projected to increase by $9 trillion in the next 10 years. Of course, those estimates didn’t include 9% unemployment continuing to depress tax collections and increasing unemployment benefits, or Obama’s increased war spending. The national debt is now $14.3 trillion (41.8% of which is owed to the Fed and Government agencies) and the Republicans are using this hostage situation to provide political cover for their responsibility and to push the blame on President Obama.

John Boehner Machiavelli by Santi di Tito

John Boehner Machiavelli by Santi di Tito

Our democratically elected leaders, Republican and Democrat, constitutionally authorized the spending, but not taxes to pay for it, which requires the Federal Government to borrow the money to pay for what Congress has spent. Not allowing our government to borrow the money needed, sounds an awful lot like fraud. Conspiracy to commit fraud.

The Federal Reserve, Treasury Secretary, head of the IMF, Moody’s and the US Chamber of Commerce have suggested that forcing a government default is nuts and will cause havoc in the markets. Surely they won’t go through with it.

Of course, there’s that other issue. Two months ago, the House Republicans voted in lockstep to turn Medicare and Medicaid in to state voucher programs. Republicans have caught a lot of flack from seriously pissed off voters since they did. Ryan’s bill was DOA in the Senate. But, now, all they have to do is get the Democrat in the White House and at least four Democrats in the Senate to vote with them on a variation of the Ryan plan. They’ll get what they want and, perhaps, have an unelectable Democrat to run against in 2012.

It’s not that the Republicans want Grandma thrown out on the street, starve or to die from lack of health care (collateral damage)*. They just don’t want to have to listen to lobbyists and their campaign contributers complain about employers being forced to pay a share of payroll taxes. Republicans would much prefer Medicare be privatized so their health insurance buddies could keep their hands in the Federal wallet. Republicans would much prefer Social Security be privatized so they could enable their Wall Street buddies to gamble Grandma’s money. Republicans would also much prefer both Social Security and Medicare become voluntary voluntary so their rich pals could opt out.

On the other hand, Republican leaders would prefer poor people and their children be thrown out on the street, starve or die from lack of health care (that’s what prisons are for). Republicans are anxious to do away with federally required Medicaid believing that until our poor are paid wages competitive with the third world, there will be no new jobs.

Their brilliant strategy is not really just about the policy. The real plot is more sinister. Should the Dems not cave, the Republicans will get what they really want – a government, at least until the next election of a Republican or they lose the House, without enough money, but with seriously higher interest rates on the deficit. The problem for Republicans is that current average interest rates on the national debt are only about three percent (3%), costing about the Treasury only about $30 billion a month. Debt is not starving the government enough. Short-term default will cause rates to double or better – benefiting rich Republican campaign contributers while also starving the government of the money needed for social programs.

So what’s gonna happen? Will Obama read section 4 of the 14th Amendment and the Perry V US court case to Boehner – “The validity of the public debt of the United States, authorized by law… shall not be questioned.”? Will the Fed just forgive their part of the debt (theoretically, they could) so there isn’t a need for debt extension? Will there be a run on Treasury debt with China and the Saudis cashing in, causing rates to skyrocket and the Fed to intervene? Will the Tea-Party Congresspeople suddenly decide what they are doing is un-American(perhaps, Michelle Bachmann will say so)? Will the business lobby (aka: the Chamber) start calling Republicans and threatening something worse then death to get the needed debt increase passed? Will the Senate pass a version of whatever comes out of the House – hoping members of a conference committee could turn it into something tolerable? Will Obama blink – hoping that voters will be so outraged that Republicans are voted out of office in 2012 and the law can be overturned? Stay tuned. Whatever happens, the Republicans are risking the world and they plan to win – no matter what.

 

* Grandmas who practice personal responsibility and free-market capitalism, don’t have to worry. Unless she gets cancer. Or helps her unemployed children. Or worked for a firm that underfunded her pension. Or her job was off-shored. Or her children grow up to be Republicans.

Winning the Unpopular Vote

We the Republicans © Dana S. Rothstein #133535On face value, it might seem stupid to run for office on issues sure to piss off the majority of people. Take, for instance, the Republican party (please). They are, of course, against Democrats who make up 34-45% of the US population, depending on the day and who’s counting. The percentage of each party varies by state or district, but generally, about 15% of the voters decide who will win and who will lose.

Some might argue, a campaign of inclusion (suggested search term: democracy) would be the best way to reach that 15% swing vote. So how do the Republicans expect to win elections when they are also in lockstep against:

  • People on Medicare (at least, 15% of US population)
  • People on Medicaid (at least, 12.6% of US population)
  • People who are unemployed (at least, 9.1% of US population, unless you also include those of us who have given up or work multiple jobs, etc.)
  • People who believe abortion should be legal (at least, 56% of US population)
  • People who believe and are concerned about global climate change (at least, 71% of US population)
  • People without health insurance (at least, 14.3% of US population – under 65, not eligible for Medicaid)
  • Immigrants (at least, 13% of US population, most all of us if you go back a few generations)
  • Blacks (at least, 12.6% of US population)
  • Union members (at least, 12.1% of US population)
  • Government workers (at least, 4% of US population)
  • LGBT (at least, 3.8% of US population)
  • Muslims (at least, .6% of US population)
  • Agnostic and athiests (at least, .9% of US population)
  • Plus, all those little groups, including elites, people who believe in science, are against guns, war, monopolies, corporate funding of campaigns, listen to NPR, don’t watch Fox, etc.

You shouldn’t just add these numbers up. People are members of more than one group. Groups don’t vote as a block. And people are more likely these days to vote against a candidate or even a single issue than for one. But with only 15% in play, it still doesn’t seem to pass a logic test that this Republican strategy can be successful.

It might surprise you, but according to Gallop,

“The most balanced political states in 2008 were Texas (+2% Democratic), South Dakota (+1% Democratic), Mississippi (+1% Democratic), North Dakota (+1% Democratic), South Carolina (even), Arizona (even), Alabama (+1% Republican), and Kansas (+2% Republican).”

Each of these states voted for McCain in the 2008 Presidential election. Each with a Republican governor, Republican upper and lower house majority, with a solidly Republican US house delegation, and at least one Republican Senator (only South Dakota, North Dakota and Mississippi had a Democrat Senator).

How is that possible in these “balanced” states? Assuming vote counting was accurate, the only answer can be that it is about who votes, and more importantly these days, who doesn’t vote.

Let’s start with voter suppression 101:

  • Make it hard to vote. Limit early voting to a few inconvenient locations away from poor areas with limited hours, few machines and rumors of long lines. Force people to take time off from work, give up their hourly pay and put their jobs at risk. Works particularly well for people who are struggling.
  • Require a valid photo ID. This works well for those who are older and may not have a drivers license or be able to afford to apply and pay for an alternative. It is also effective to keep away the homeless or those whose identification doesn’t reflect an accurate address because of eviction, foreclosure or change of status.
  • Purge the voter rolls. This is very popular, effective and there a lot of variations to the scheme. Mismatch names or social security numbers and make people prove they aren’t who some computer thinks they might be (suggested search terms: Georgia purge voters). Or prove they are citizen. Or make them wait in long lines to vote on a provisional ballot that may not be counted.
  • Create long lines. Easy to do. Just send few voting booths to the polling place you want to suppress and more to the polling place you wish to help. Also very effective to provide few people or broken machines. Long enough lines, and people will go home (suggested search term: Ohio long lines polls).
  • Caging lists. Republicans send out registered mail to the address of a voter in a district they wish to suppress. If returned, they contest the ballot. Expected to be particularly effective with the foreclosure crisis.
  • Robo calls. Hire your telemarketer to call registered voters who you don’t wish to vote and tell them their polling place has changed. Or they’ll be arrested (suggested search term: Virginia robo calls vote).
  • Contest new registration. A favorite of Republicans during the last few cycles. Republicans have attempted to force verifications of mail in forms. They have even offered rewards to find bogus registration by community groups and have threatened prosecutions.
  • Make absentee ballots as confusing as possible. Seems obvious. Put the right information in the wrong place and your vote doesn’t count.
  • Prison disenfranchisement. 5.3 million mentally competent and able adult Americans (we are the only democracy in the world that does it) are not allowed to vote because they have been either incarcerated, on parole or on probation. Click here for a state list.
  • Pray for rain, sleet, snow, dark of night. Surely, the Republicans will do this. Time will tell if it will be effective.

In 2008, more than 130 million people voted – the highest percentage in a generation. The surge of voters were mostly among black, Hispanic and young voters. Without that higher turnout, McCain would have won. The Republicans are counting on making your life so miserable this time around that you stay at home.

What a Week

President Obama at White House Correspondents DinnerDuring Friday night’s White House Correspondents Dinner, President Obama paused during his remarks, smiled thoughtfully and said, “What a week.” We had no idea.

In addition to his everyday duties, briefings, meetings with the National Security Team, the Attorney General, Defense Secretary,  Secretary of State, Congresspeople, Governors, etc., doing press interviews, hosting Crown Princes and Presidents, working to fix our immigration problems, manage a few a wars, and commemorating the 1968 Memphis sanitation strike, our President took time to do a few more things that made last week seemed pretty amazing.

It started out ordinary enough as he and the first family hosted the Easter Egg Roll. By Wednesday morning, he and Michelle were in Chicago doing Oprah, then to New York for a fund raiser and back to Washington. Thursday, he announced a new National Security Team and presented his long form birth certificate. Friday he and Michelle were in Alabama to view the storm damage, meet with Governor then on to Florida to meet with Rep. Gabrielle Giffords and view the final space shuttle launch. Fortunately, the Endeavor  was aborted (still legal), so he could get back for the Correspondents Dinner and a relaxing weekend at the White House. All that was planned, was his Saturday address announcing a plan to end oil subsidies at this time of record oil company profits;  the special ops mission to take out bin Laden and a relaxing bipartisan dinner Monday night with leaders of both houses to informally discuss the budget and Republican plans to hold the nation hostage on debt ceiling. OK, that was eight days.

Recapping: Easter Egg Roll; Oprah; new National Security Team; long-form birth certificate; Libya; immigration reform; multi-state natural disaster; Correspondents Dinner; announce plans to end oil subsidies; take out bin Laden; host bipartisan dinner to talk about the budget; help kids with their homework. The reviews aren’t all in, but early reports suggest it was a pretty good week.

Monday:

Wednesday:

Thursday:

Friday:

Saturday:

Monday:

What on his schedule this week?

Southern governors (all but one, Republican), report the Federal response to the disaster has been almost perfect – Google “Bush Katrina” to be reminded of the political risk of natural disasters. This week and next, of course, he’ll also be dealing with the greatest flood surge along the Ohio and Mississippi Rivers since 1927.

Celebrations have broken out evoking a sense of relieve and patriotism not seen in decades – Google “Carter Hostage Rescue” to be reminded of the political risk of precision military operations. Perhaps, we should also be reminded that it was during last week, that NATO missiles missed Gaddafi and killed his son and grandchildren – something that President Obama will be dealing for a while.

And then there is debt ceiling. Is it possible that Republicans, back fresh from two-weeks being yelled at by constituents for voting to end Medicare and Medicaid, stinging from watching a competent president succeed where others failed, and flushed with patriotism for the bin Laden mission, will do what’s important for our country and pass the debt ceiling? Or will they march as lemmings off a cliff and take the world’s economy with them? That’s something that President Obama has already started working on this week. The Washington Post reports that the Treasury Department has begun implementing some emergency measures that buys 25 more days than expected to solve the political issues – we have now until August 2nd before default. Stay tuned. The week has barely just begun.

Update 05.03.11: Reuters reports the Mississippi River dropped a foot within hours of levee detonation and the NY Times reports it saved Cairo, IL. Obama has more work to do, though, the Army Corp of Engineers warns the river may rise again and isn’t expected to crest in New Orleans until May 22nd.

Update 05.03.11: Newsweek/Daily Beast reports the week might not have been so good. In a survey just completed, President Obama got no post-bin Laden bump in approval ratings saying, “The clear reason: It’s the economy, stupid. Even after Bin Laden’s death, only 30 percent think the country is on the right track, and only 27 percent think the economy is on the right track.”

Update 05.03.11: Not so fast, the Los Angeles Times reports a survey released by the Pew Research Center for the People & the Press and the Washington Post, shows President Obama’s approval rating jumping nine points post-bin Laden to 56%; a CNN/Opinion Research Corporation showing a four-point bump to 52%; USA Today/Gallup poll finding “32% said they feel more confident in Obama as commander while 21% said they feel a little more confident;” and “Ipsos-Reuters poll said that their view of Obama’s leadership had improved in the wake of the raid.” The Times went on to say, “Overnight polls are notoriously fickle and often differ from each other on the questions asked and the numbers computed.”

Update 05.03.11: Over a drink together, Chris Matthews reminded me that on Friday, President Obama also gave the commencement address at Miami-Dade College (4/30/11), let’s watch:

Update 05.04.11: CBS News reports a “new CBS News/New York Times poll found that 57 percent of Americans generally approve of Mr. Obama in the wake of the raid in Pakistan. Two weeks ago, when bin Laden was still America’s most-wanted terrorist, the president’s overall approval rating was at 46 percent. A whopping 85 percent of those polled gave Mr. Obama high marks for his handling of the operation to find bin Laden.”

Update 05.04.11: Channel 6 News reports the Army Corp plans to blow additional sections of levees along the Mississippi in Mississippi County, MO; New Madrid, MO; and Hickman, KY. Tough decisions. Huge stakes in the lives of residents and politically for the Obama administration.

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.

Hold your nose and swallow

medicinekidsClose your eyes. Hold your nose. Open your mouth. Now swallow. – That’s how my mom tried to keep me from gagging when taking medicine. That’s what our Democrat leaders are telling us now about health care “reform.”

Another gigantic example of big event legislation. A massive bill way too big to fail – or read – or understand – or debate. Chock full of things for just about every special interest so Dems can finally deliver a health care bill.

  • No insurance? We’ll give it to you.
  • Can’t afford insurance? We’ll help you.
  • Uninsurable? No longer.
  • Have insurance? We’re not going to change a thing.
  • On medicare? We’ll close the prescription donut hole.
  • Own insurance or pharma stocks? We’ll increase your markets and your profits.
  • A health care provider? We won’t set prices.
  • Against a woman’s right to choose? Us, too.
  • Against expanding Medicare? Us, too.
  • Against a public option? It will be in name only.
  • Anti-deficit? It’s paid for with savings and new taxes.
  • Anti-health care reform? Your state can opt out.
  • Anti-Obama? Won’t go into effect until after the next presidential election.
  • Anti-immigrant? Us, too.
  • Own a business? Have we got some loopholes for you.
  • Middle class poor with lots of debt? Okay, nothing for you, but didn’t we just pass a tax cut and credit card reform?
  • Healthy and just starting out? There are no jobs anyway, go for Medicaid.
  • Work on K Street? You’ll make your bonus.
  • An accountant or lawyer? Consider it a bailout.

H.R.3590 – Service Members Home Ownership Tax Act of 2009 (this is the actual name of Senate health care bill which is an amendment of a bill already in the cue to speed it up – aka: The Patient Protection and Affordable Care Act) runs some 2,074 pages containing 327,911 words (War and Peace has 561,893 words). It is the poster child example of the preferred way to govern these days: one gigantic omnibus bill that no one authors (or is to blame) and no one really knows who (or what lobby firm) added or compromised what that ends up in it. Bills that can be labeled, branded, lobbied, spun and base-rallied pro or con. Legislation to do everything, will last forever and we’ll fix down the road, depending upon who is in the majority down the road. This type of legislation is the reason politics is so partisan. And, this is what I hate about health care reform.

Dew_BillWordCounts

Note on the numbers in the chart: I downloaded the documents (transcripts of the older document) and used Microsoft Word’s word count tool. Some of the documents included signers, secretary notes, enactment dates, and other information that may cause count to vary slightly.

Couldn’t we have broken out a few things that we all believe in? Small, understandable bills that could be bipartisan? Simple language to solve some basic problems that simple people could believe government could actually accomplish? Incremental reforms to fix what we all might agree is broken?

  • Why do we have to debate the public option to get rules changed so preexisting conditions don’t prevent people from getting insurance?
  • Why do we have to debate whether every business will be forced to offer – and every individual will be forced to have – insurance in order that individuals and mom and pop businesses are allowed to join group plans at a reasonable cost?
  • Why do we have to agree not to negotiate prescription prices in order to have higher penalties for people who commit Medicare fraud?
  • Why do we have to debate subsidies for the uninsured, just so we can get rid of subsidies of private insurance companies offering Medicare (or at least require them to report quality of care results)?
  • Why do we have to debate changes in tort so that we can pass legislation to cover newborns who don’t have insurance?
  • Or require reporting on the effectiveness of drugs, medical tests and procedures? Or require electronic reporting? Or remove lifetime limits? Or limiting waiting periods? Or insurance plan transparency? Or transparency of physician ownership and investments? Or investments in primary care provider training? Or nursing student loans? Or funding for a National Health Service Corps? Or a national and state background checks for facilities and providers? Or medical bankruptcy prevention? Or improvements in access to immunizations? Or addressing childhood obesity? Or hospice reform? Or chronic disease prevention? Etc.

Wouldn’t it seem more civilized to pass specific bills that we agree on rather than bundling those we agree on with a bunch of controversial issues forcing our representatives to vote up or down on the whole package – or, God forbid, break with their party?

Why can’t we have a separate debate/vote on a public option or expanding Medicare? And a separate debate/vote on allowing insurance companies to compete in national markets? And a separate debate/vote on requiring everyone to have some form of coverage?

What is really going on here? Our leaders just don’t have much faith in us. They act as if they believe that the only way they can build a constituency to pass a bill is to make the issue seem to have epic proportions. To frame a debate as one that threatens our existence or our way of life. To excite the base, shake out the campaign contributions, get TV face time and get reelected. They did this to invade Iraq (Vietnam, Korea, Philippines, Mexico, Indian Wars, etc.). To bail out Wall Street (protect many other industries). And now, to pass health care “reform.”

We need our health care industry reformed. We must find ways to stablize costs. We must become more efficient and more competitive. We must do better in preventive care. We must discuss as a society, how the poor, the unfortunately sick and the innocent should receive health services. We also must find common ground, or we may lose more in the process than gained by any victory or defeat of the bill.

This bill is not about really about “reform” – I sincerely wish it were since I hear and read so much about it. Don’t get me wrong – there is a lot of great stuff mixed in the 2,074 pages – important, life-improving and life-and-money-saving stuff. But much of this bill and almost all of the cost, is about expansion of health care insurance for those who can’t afford insurance, don’t choose to buy it (preferring, in most cases I suspect, to eat or have shelter), or have been denied it. Reform is mostly packaging.

As a result, we’ll probably get a compromise of a “reform” law. A compromise of a benefit for the uninsured. Certainly a more divided country. And, we’ll probably have to do it all again some day soon because many of the real issues won’t have been honestly included, debated in daylight, voted on, or made sustainable.

On the other hand, what an historic achievement to get it this close. Maybe it really does take this cynical, scare-the-hell-out-of-everyone, Rahm Emanuel-pit bull-but-open-to-compromise-approach to get something done? Please weigh-in with your comments.


Suggested Reading:

You Bastard

The Atlanta Journal today reports that Gov. Sonny Perdue is going to provide property tax relief to homeowners. Sounds good, right? Not really. His scheme is use the $460 million in Medicaid stimulus money Georgia’s to get, cut what Georgia would have provided to our most needy citizens, cut $99 million from K-12 education and another $20 million from Georgia’s universities (K-12 and the universities we cut $150 million this year already), and borrow $150 million from Georgia’s reserves to do it. Robbing our children. Robbing our sick. Robbing our potential. Robbing our competitiveness. Make me hope there’s a hell.