Wednesday, March 17, 2010

A Re-Cap of the Progress of the POS: 9/09-11/09

First, a re-examination of the mess we got ourselves into.

Wednesday, September 16, 2009

What IS Affordability?

So now attention is being been paid to the Senate Finance Committee memo linked to in The New Republic by Jon Cohn. In 4 mildly-worded pages, it lays out a fantasist's idea of health insurance affordability that only cossetted, in-the-tank boneheads like Max Baucus and his ilk (which is to say, your average well-insured legislator) could find “affordable”. The maximum premium cap laid out in this plan is 13.9% of income. Bear this in mind for later.

But the best thing about it is that it begins to quantify what has heretofore been merely a slogan. What does affordability mean?

There has been no secret about the model on which these changes would be crafted; it's the Massachusetts Mess, and a simple exercise worked out on its convenient Commonwealth Connector website offers anyone who wants it, the opportunity to be a Bay Stater for a moment. A moment, I'd add, that once past, you will wake from in sweaty terror, clinging in sheer relief to the knowledge that you are free from that nightmare, for the nonce at least. Let's take a look at what the plan offers to an older couple not yet ready for Medicare, making a decent but not excessive living of about $86,000 per year.

First, we know the couple will not be eligible for Commonwealth Care, which is basically a public option, because it is only open to couples making less than $43,716 per year. We also know, from using the handy “affordability tool”, that our couple makes $1000 per year too much for subsidies, and so is considered fair game for any insurance plan offered. (Better hope your income doesn't vary from year to year, or the headaches won't be the kind your prescription drug plan can fix.) So let's go straight to the private insurers.

The plan offers 3 levels: bronze, silver, and gold, just like Olympic medals. See that? Don't you already feel like a winner? First, be aware that out of pocket spending in all plans is limited, to a mere $10,000 per year. Whew! Dodged a bullet on that one, eh?

Let's examine the highest and lowest cost plans offered. First, Harvard Pilgrim Health Care:
$960.12 per month, or $11,521.44 per year. 13% of total income.
What do we get for this princely sum? Well, first, the deductible: $3500. Then:
Doctor visits: $25 copay for up to 3 medical care office visits per individual (or 6 per family); the next visits are subject to the deductible; then 20% co-insurance thereafter.

ER visits: $250 (watch those kitchen accidents!)

Hospital stays: Deductible first, then 20% co-insurance

Prescription drugs: Separate deductible of $500, then $15 for generics, 50% co-pay all others

In a bad year, if our couple should have to use up their deductible, the total cost including premiums would be $21,521.44, or 25% of total income. And that doesn't even include the co-pays, drugs, or other spending, which will raise that percentage much higher.

For the highest cost, leave it to Blue Cross Blue Shield of Massachusetts:
$2,293.73 per month, or $27,524.76 per year. 32% of total income.
Ah, but here's the diff—NO deductibles. None. Nada. Nil. The co-pays are rare and much more reasonable, and involve no nasty surprise balloon payments:
Doctor visits: $15 co-pay (no limits on visits)

ER visits: $100

Hospital stays: $100

Prescription drugs: $10/$25/$45
In a bad year our couple will not pay much more than their premium payments, or $27,524.76 per year. 32% of total income. In other words, the same amount that they paid out in premiums, not counting a few small co-pays that, unlike the "cheap" plan, will not add up to anything worth sweating.

The difference between costs of the plans in a worst case scenario year is about $6000. But the problem is that with those hospital and drug co-pays in the “cheap” plan, a serious illness or accident could easily end up bankrupting or impoverishing a family, while that $6000 will be mostly all the family with the expensive plan will have to eat. Another safety valve, that of preventive care, also gets cocked by the “cheap” plan. The family that takes it out gets raked over the coals by premiums, and finds the co-pays and hoops so onerous and difficult that it may forgo treatments altogether. So those who go for the lowest cost end up feeding the corporate beast with little security to show for it, and are 13% poorer for the privilege.

But don't take my word for it. Public Citizen looked at the real-life situations of Mass citizens this past February, who had very little good to say about it. People are still falling through coverage gaps, still finding themselves unable to access care, worse off with less money to spend as the insurance companies rake in profits from their captive market. This is not the model for national health care. This was an experiment, and experiments are done to learn from mistakes.

Let's learn from this one.

Wednesday, September 23, 2009

Cost Containment Is Inherent in Single-Payer

At Counterpunch, David Lindorff makes a persuasive argument for the inherent cost savings of a Medicare-for-all plan:
"Medicaid, the program that pays for medical care for the poor, and is funded by federal and state taxes, would be eliminated, saving $400 billion a year. 
Veterans’ care, currently running at $100 billion a year, would be eliminated.

Perhaps two-thirds of the $300 billion a year spent by federal, state and local governments to reimburse hospitals for so-called “charity care” for treatment of people who have no insurance but don’t qualify for Medicaid, would be eliminated.

Individuals and employers would no longer have to pay for private insurance.

Several hundred billion dollars currently spent on paperwork by private insurers would be eliminated.

Car insurance would be cheaper as there would no longer have to be coverage for medical bills.

Federal, state and local governments would no longer have to pay to insure public employees.

In short, if every person were on Medicare, the overall savings would overwhelm the small increase in the Medicare payroll tax of 5.8%."
I would add that federal incentives to make going into primary care more attractive than specialties, and requiring service in under-served areas in exchange for those incentives, might go a long way to  keeping costs down, as well as injecting a much-needed correction into the expanding gentrification of our health care continuum.

Thursday, October 01, 2009

Tearing Down the Wall of Our Humanity, One Brick at a Time

Chuck Grassley continues to disgrace himself with his petty, opportunistic hatchet blows at what's not going to end up as our health care reform bill anyway:
"Senate Finance Committee Democrats rejected a proposed a requirement that immigrants prove their identity with photo identification when signing up for federal healthcare programs.

Finance Committee ranking member Chuck Grassley (R-Iowa) said that current law and the healthcare bill under consideration are too lax and leave the door open to illegal immigrants defrauding the government using false or stolen identities to obtain benefits.

Grassley's amendment was beaten back 10-13 on a party-line vote.

The bill, authored by committee Chairman Max Baucus (D-Mont.), would require applicants to verify their names, places of birth and Social Security numbers. In addition, legal immigrants would have to wait five years, as under current law, after obtaining citizenship or legal residency to access federal healthcare benefits such as Medicaid and the Children's Health Insurance Program or receive tax credits or purchase insurance through the exchange created by the legislation.

But the would not require them to show a photo ID, such as a drivers license. Without that requirement, the bill "remains dearly lacking when it comes to identification," Grassley said. "Frankly, I'm very perplexed as to why anyone would oppose this amendment," he said."
Well, it's not hard to perplex a man who will parrot any damned crazy crapola his  party's morons make up, and is happy to exploit the nativist panic over our immigrant population.  Why are they always so quick to deny care to the very people who basically wipe the nation's ass for it because white people are too busy?  They may not want to take care of sick immigrant children (and what the hell do the children have to do with it? where is all this "pro-life" bushwa when it counts?), but they don't object to them dying for us in Iraq.
As of February 2008 there were about 65,000 non-citizen and naturalized immigrants in the armed services--people who would have to wait five years under Baucus'  bill before we would deign them worthy of health care.  Here are some stats:
All this whinging about how immigrants are stealing our cheese conjures to mind an image of a chandelier of an old lady, bejeweled about the dewlaps, clasping tightly at her purse as a ragged child in the street tries to sell her a box of matches.  "Oh God!" she shrieks, "Get her away!  She's probably capable of anything!  She'll take everything I have if I let her get any closer! Oh, take me home, James!"  Upon which she's off to her estate for a formal dinner as the child dies in the gutter.

What a disgraceful panorama of hypocrisy and faux-Christianity.  But thank God Max got his.

Thursday, October 29, 2009

Get A Grip

Mind if I piss in the punch bowl?

While everyone else is wahooing and celebrating the new House Health Care Reform plan, I have to ask: is this really what I'm supposed to break out the champagne for? Limits on premiums that allow insurance companies to gouge people living at 400 percent of poverty for 12% of their income? For a family of 4 making $88,200, that's a yearly total of $10,584 just to pay for the privilege of having something called "insurance". But wait, there's more. Once you've paid to "have" insurance, you may then have to actually "use" it. Now what would you pay??

Well, that's a whole 'nother kettle of fish, my friends. But don't worry! This fabulous bill "prevents bankruptcy" (that's really what it says) by capping total out-of-pocket spending for covered benefits that cannot exceed $5,000 for an individual and $10,000 for a family. So our family of 4 at 400% of poverty can look forward to shelling out, at most, no more than $20,584 during the year in a worst-case scenario, provided the medical expenses are ones covered by their policy.

So this means that now our hypothetical family will need to put aside only 23% of their income for medical care. That year. Because, of course, they might have to incur the same amount of debt next year, too. And if someone is hit by a particularly nasty illness or impairment, it could go on that way for years. No worries about bankruptcy now, eh?

And you know what the best part of this culmination of our fight for universal coverage is? It won't even be universal: an estimated 18 million people will remain without insurance. But it's all good. The CBO has given its blessing, and in the end, it's really only the price tag that wags this dog. Parsimony wins the day when it comes to saving lives, because there's lots more money needs to be shat down the Pentagon/contractor toilet to make the world safe for Wall Street. The odd thing is that Pelosi backed off a public option that would dictate fees for providers, and instead went with negotiated fees, which all agree will add expense to the system. And despite all the whinging about how budget-busting a single-payer system would be, there's this:
"The new House bill would expand Medicaid to cover childless adults, parents and others with incomes less than 150 percent of the poverty level, or $33,075 for a family of four. This goes beyond the earlier House bill and a companion measure in the Senate, which would extend Medicaid to people with incomes less than 133 percent of the poverty level ($29,327 for a family of four).

This change saves money. It is less expensive for the federal government to cover low-income people under Medicaid than to provide them with subsidies to buy private insurance."
I tell you, I love the smell of hypocrisy in the morning. Smells like...Congress.

Ah, life is good. Now let's see how that financial regulatory reform is coming.

Sunday, November 01, 2009

Once More Into The Affordability Breech, Dear Friends

If I'm going to bitch about every health care reform plan that comes out of Congress, I suppose I'd better explain what I think affordability means. It does not mean 10% of one's income for premiums, and it does not mean another 10% in deductibles and out of pockets before one's insurance actually begins doing what you have been paying it to do.

With regard to expanding utilization of current programs:
  • First, Medicare drops to cover everyone 40 years old and older. Age discrimination law protects all those over 40, and many illnesses begin to manifest after this age, so this seems a good starting point.
  • For those under 30, the option to stay on their parents' or guardians' insurance.
  • For the low-income, Medicaid up to an income of $25000, no matter the size of the family.
Regarding the cost of insurance premiums for everyone who doesn't fall into the above categories, no more than the following % of income, on a sliding scale:
$25,999—1% ($260 yr, $22 mo)

$30,000---2% ($600 yr, $50 mo)

$70,000---3% ($800 yr, $67 mo)

$100,000—3 ½ % ($3500 yr, $292 mo)

$150,000---4% ($6000 yr, $500 mo)

$200,000---5% ($10,000 yr, $833 mo)

$250,000---6% ($15,000 yr, $1250 mo)

$300,000---7% ($21,000 yr, $1750 mo)

$400,000---8% ($32,000 yr, $2667 mo)

$500,000---9% ($45,000 yr, $3750 mo)

$1 million and up---10% ($100,000 yr, $10,000 mo)
The excess amount charged to those in the higher income categories can be used to underwrite the costs of insuring those in the lower-income brackets.

What the above chart tells you is that:
1)  No insurance company, no matter how venal, is ever going to charge $100k a year for a family's insurance. This means that the rich will always be at advantage over the poor when it comes to paying premiums. If you found yourself looking at that chunk of the millionaires' share and thinking, “Wow! That's a little steep!”, just imagine how more more cruel that 10% will be on the backs of those with only a fraction of that income; and

2)  Even a small percentage, taken from a limited income, is going to weigh heavily on that family or individual in ways that could break them if other expenses are not taken into consideration.
Deductibles and out of pocket cost limits should be minimal, rare, and for very extraordinary situations; say, cosmetic surgery for purely vanity reasons. For those paying 1% of their income for premiums, they should not exceed the cost of those yearly premiums. For those paying 3-6%, they should not exceed twice the cost of those yearly premiums.

The regulations allowing direct-to-consumer advertising of prescription pharmaceuticals should be eliminated, to cut down on the costs of those drugs ( % of drug company costs are related to advertising and marketing) and reduce patient demand for drugs that may not be appropriate or advisable for their situations.

Accountability should be created by requiring insurance companies to provide regular yearly financial statements to their customers showing where their profits are coming from and where they are going, including top executive salaries and all political contributions and PAC connections.

No this isn't meant to be comprehensive, but it give you an idea of where I'm coming from.

Sunday, November 08, 2009

Not So Fast

Yes, I know, everyone's breathless over the passage of the House health reform bill. But just remember this: requiring people to pay for insurance does not mean they are going to get health care:
Because of costs, Massachusetts hasn’t solved the problem of guaranteeing access to health care. Even residents with coverage can’t afford medical treatment because of co-payments and the charges that insurance doesn’t cover, according to a September 2009 report by the Kaiser Family Foundation with headquarters in Menlo Park, California.
This is how you get a 97% coverage rate that looks good on paper: you force people to buy coverage that drains their budgets and costs so much to use that they can't afford to get the health care this was supposed to be about in the first place.

This is what I fear is coming down the pike from our millionaires in Congress, too, where a cap of $12,000 on premiums is considered affordable, and allowing insurance companies to charge older people twice what they charge younger ones is a fair deal.

And as for those vaunted cost savings? Not so much in the Bay State:
Private insurance premiums in the state rose more than 12 percent through the end of 2008, according to an Oct. 21 report in the New England Journal of Medicine co-authored by Massachusetts Health and Human Services Secretary JudyAnn Bigby. The cost of buying insurance increased 10 percent so far this year, the report said.

Price increases like these put pressure on the finances of businesses that provide insurance to employees, workers who pay part of that cost and individuals who buy their own coverage.

“President Obama is a visionary and he’s going to use Massachusetts as an example of how his ideas might play out,” said Regina Herzlinger, an economist at Harvard Business School in Cambridge. “But Massachusetts is a wealthy state and it can afford things that other states cannot. And even now Massachusetts is having trouble.”
I will grant you that Massachusetts put the cart before the horse and rushed everyone into eating an insurance plan before cost reductions had been worked out. But the essential flaw in the system--the idea that you can craft a device that will affordably grant health care to the masses while ensuring corporate profits--is going to cripple every attempt to fix it until it is recognized for the myth it is, and the free market is eliminated from basic health care coverage.

Tuesday, November 10, 2009

It's Over

I've given this a lot of thought, and it's really hard for me to say it, but it's time to kill this bill. The Stupak amendment was just the final straw. It will create a de facto ban on abortions as effectively as if the old laws of the pre-Roe era were back in place. That it will do so within the context of a bill that will lay an enormous financial burden on the middle class without providing them nearly enough real health care compensation in return, is simply unsupportable. I'm with the 41 liberal House Dems who have told Pelosi they will off the bill in conference if the amendment is not removed. The line has finally been crossed, and it's time to junk this thing. For those who say it can be fixed in incremental changes over time, I say, look at how the Hyde amendment and the ripples created by Casey v Planned Parenthood have been changed over time: states and even reactionary federal governments have turned the screws on women ever tighter, until a legal medical procedure has become basically unobtainable to women in 87% of the country. If our elected Democratic officials, riding a wave of anger so palpable that a black man with an Arabic-sounding name could be elected President of the United States, were unable to craft a law that put the needs of their people ahead of their own trifling self-interest, why on earth would anyone think a different breed of politico is going to come down the pike in 5 years and fix it later?

And if you think this can eventually be corrected by the Supreme Court, you haven't been paying attention to the Roberts court decisions.

Too many cowards taking our tax money to sell us down the river. Too many bad decisions about to become enshrined in law. I'm out.

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