Monday, November 09, 2009

The Health Care Reform Bill

I got an e-mail from my Congressman, Scott Garrett, with a link to the Health Care reform bill, HR 3962, and a list of specific areas he wanted to bring to my attention. Although he didn’t say so, I have to assume that these are areas of major concern to him.

Having learned a long time ago to NEVER accept anyone’s unsupported word for anything, I checked the references in the e-mail. This was probably the last thing Garrett expected anyone to do. To say that, in my opinion, most of Garrett’s descriptions were either misleading or flat out wrong would probably be fairly close to accurate.

Garrett has applied in his e-mail a number of propaganda techniques aimed at winning an argument on the emotional level without having to worry about little things like facts. The first is a time honored propaganda technique called “name calling.”

In “name calling” one attempts to attached labels with negative connotations onto a person, policy or idea. Garrett throws around terms like “bureaucrat-approved” and “job-killing” without ever justifying the assertions associated with the terms.

The second technique is an appeal to fear. He uses this technique when talking about abortion, jobs and Medicare, subjects guaranteed to be emotionally charged. Again without ever justifying the assertions, he implies the loss of jobs and a reduction in Medicare benefits.

The interesting part is that his assertions are not necessarily wrong, but I tend to be suspicious when someone appeals to emotion and fear rather than addressing the facts.

Garrett’s e-mail is also a classic example of “accurate but misleading.” The best way to illustrate this approach is with an example. Back in the dark days of the cold war there was a race between a Soviet horse and an American horse. The American horse won. The next day in the Soviet newspapers was the following perfectly accurate story.

“Yesterday, in an international horse race, the glorious Soviet entry finished second while the American horse finished next to last.”

Congressman Garrett’s list of sections of particular interest, complete with commentary:

Page 94Section 202(c) prohibits the sale of private individual health insurance policies, beginning in 2013, forcing individuals to purchase coverage through the federal government.

This is so misleading I’m having a hard time considering it accurate at all. Technically this is accurate if one accepts buying insurance via the proposed insurance Exchange as “through the federal government.”

The implication that individuals must buy a government issued insurance policy is flat out not true. There will be the public option available but private policies will be available as well.

Having individuals buy insurance through the Exchange actually strikes me as a very good thing for several reasons. Most individuals don’t have the expertise to know a good policy from a worthless one. Policies available through the Exchange would be screened for them by experts from the Department of Health and Human Services like drugs are screened by experts from the Food and Drug Administration (FDA) and aircraft and airlines are screened by experts from the Federal Aviation Agency (FAA).

It also supplies a one stop shopping venue for individuals and companies. If the Exchange also issues guidelines and a Frequently Asked Questions (FAQ) area it could actually turn out to be quite valuable in helping people get the insurance they actually need rather than what the insurance companies want to sell them.

Page 110Section 222(e) requires the use of federal dollars to fund abortions through the government-run health plan—and, if the Hyde Amendment were ever not renewed, would require the plan to fund elective abortions.

This is accurate but misleading. What the bill does is require the government-run health plan to abide by whatever law is in place relating to what, if any, abortions may be funded by Federal funds. It places no requirements with respect to abortion on private health care plans nor does it place any restrictions with respect to abortions on private health care plans.

The Hyde Amendment restricts abortions that may be paid for via appropriations to Health and Human Services. Specifically it prohibits the use of Medicaid funds for abortion other than in the case of incest, rape and when the mother’s health is endangered. Section 222(e) REQUIRES the Public Health Option (PHO) to support the services allowed by the Hyde Amendment but it does not prohibit the PHO from covering services disallowed by the Hyde Amendment.

So it is true that if the Hyde Amendment were ever not renewed, then the PHO would be required to cover elective abortions. However the PHO may chose to cover these services regardless of what happens to the Hyde Amendment.

Page 111Section 223 establishes a new board of federal bureaucrats (the “Health Benefits Advisory Committee”) to dictate the health plans that all individuals must purchase—and would likely require all Americans to subsidize and purchase plans that cover any abortion.

Yes a Health Benefits Advisory Committee (HBAC) would be established but that’s about all that’s accurate with this statement. The HBAC would be an expert committee and what it would be chartered to do is “recommend benefit standards, and periodic updates to such standards.”

In other words the HBAC recommends adjustments to keep the health plan definition up to date with the latest best medical practices. It would be idiotic NOT to have an expert committee to review and recommend updates and changes.

The Secretary of Health and Human Services would decide what recommendations, if any, to accept and then only after the publishing of the recommendations and public debate.

They wouldn’t be “federal bureaucrats” either. According to section 223(c) the members would receive travel expenses and per diem but no additional pay. Section 223(c) also states that they are not to be considered federal employees purely as the result of being an HBAC member.

The second part is absolutely not true. As a matter of fact Section 222(e) clearly prohibits the Health Benefits Advisory Committee from recommending ANY abortion service, including those that may be legally funded by Federal funds, and prohibits ANY abortion service as being required for a Qualified Health Benefit Plan (QHBP).

Page 211Section 321 establishes a new government-run health plan that, according to non-partisan actuaries at the Lewin Group, would cause as many as 114 million Americans to lose their existing coverage.

This is an appeal to fear. Section 321 certainly establishes a public QHBP. How that would cause anyone, never mind a third of Americans, to lose their existing coverage is unclear to me. I scanned the Lewin Group report and I see no basis for the 114 million number. What the Lewin group does predict is that the number of individuals covered by employer insurance will decline by 7.3 million.

They estimate that 19.1 million workers and dependents will lose their employer supplied insurance (ESI) as the result of the employer dropping insurance when the expanded Medicaid and premium subsidy programs become available. They predict this would be offset by an 11.8 million increase in coverage by employers that want to avoid the penalties leaving a total of 7.3 million.

They also evaluated a different form of the bill. They evaluated the bill passed by the Senate Finance Committee.

One concern I have is I thought that any public option would be an option of last resort. This looks to me like they are setting up a competitive option. I’m not sure why the government would want to get into the Health Insurance business.

I would like to better understand the implications of the public option.

Page 225Section 330 permits—but does not require—Members of Congress to enroll in government-run health care.

Why would the bill want to “require” Members of Congress to enroll in the government-run health care plan? It’s not requiring anyone else to enroll in the government-run health care plan. This is an appeal to fear. The implication is that the public is being stuck with something so inferior that Congressmen themselves wouldn’t want any part of.

Yet apparently, according to the Republicans, this public option is going to be so good that those kind hearted capitalists we’re supposed to put all our trust in and wait for the “trickle-down” are going to choose to dump their employees onto it. Or it’s going to be good enough to drive insurance companies out of business.

Scott, a little consistency would be nice.

Page 255Section 345 includes language requiring verification of income for individuals wishing to receive federal health care subsidies under the bill—while the bill includes a requirement for applicants to verify their citizenship, it does not include a similar requirement to verify applicants’ identity, thus encouraging identity fraud for undocumented immigrants and others wishing to receive taxpayer-subsidized health benefits.

This is accurate but ridiculously misleading. The bill clearly requires individuals receiving subsidies to be “lawfully present in a state in the United States.” It also has a provision for “Program Integrity” and requires the Commissioner to “take such steps as may be appropriate to ensure the accuracy of determinations” for subsidies.

Those “steps” would certainly include insuring that applicants were who they said they were. It just doesn’t specify how this should be accomplished. Identity theft is a crime. It is not the purpose of this bill to define how that crime should be guarded against.

This is also an appeal to prejudice. It establishes the totally unrealistic concern that somehow illegal immigrants will manage to figure out a way to essentially steal benefits. I might point out that would also be a crime, one that could earn someone a jail term and not simply deportation.

What are you trying to say Scott, that all illegal immigrants are crooks? Other than being here illegally, that hasn’t been my experience.

Page 297 - Section 501 imposes a 2.5 percent tax on all individuals who do not purchase “bureaucrat-approved” health insurance - the tax would apply on individuals with incomes under $250,000.

Here’s a little name calling. The “bureaucrat-approved” label is prejudicious and, as pointed out above, totally inaccurate. The initial definition of a Qualified Health Benefits Plan (QHBP) is in the bill and the HBAC (who I assume are the so-called bureaucrats) would simply recommend adjustments and updates.

This is the “prevent someone from playing the system” provision. This is the provision that prevents someone from not paying for coverage and then having YOU foot the bill when he gets sick because hospitals are prohibited from turning away uninsured patients. So guess who, in the long run, ends up paying for them? What’s the alternative to preventing these sort of games? Let them die?

The language also implies, incorrectly, that there is some choice other than an approved QHBP health plan. There wouldn’t be. That’s the whole point of reform. The exception, if you can call it that, would be grandfathered plans, plans already in existence which people choose to continue. Those plans and individuals would be exempt from this tax.

So if what you already have is REALLY better than a QHBP, you can stick with what you have. However allow me to suggest you compare them very carefully. I’d be very surprised if that turned out to really be the case.

Page 313Section 512 imposes an 8 percent “tax on jobs” for firms that cannot afford to purchase “bureaucrat-approved” health coverage; according to an analysis by Harvard Professor Kate Baicker, such a tax would place millions “at substantial risk of unemployment”—with minority workers losing their jobs at twice the rate of their white counterparts.

This one has all the propaganda elements. Name calling, the appeal to fear and it’s accurate but misleading. It’s not a “tax on jobs.” It’s a payroll excise tax of up to 8%. The 8% number only applies to companies with a payroll greater than $750,000. For companies with a payroll less than $500,000 there is no tax. Between $500,000 and $750,000 there are 2% steps every $85,000 dollars or so.

We’re not talking about the ma and pa grocery store here but we’re not talking Ford or Sony either. I think there is a right to be concerned about this provision but at least the bill is providing an option for those employers that chose, for valid financial reasons, not to provide health care.

To my mind the bigger concern is that, given the existence of the public option, many small employers will chose to pay the tax rather than provide the health care. I’m also concerned that the amounts do not appear to be indexed for inflation.

Page 336Section 551 imposes additional job-killing taxes, in the form of a half-trillion dollar “surcharge,” more than half of which will hit small businesses; according to a model developed by President Obama’s senior economic advisor, such taxes could cost up to 5.5 million jobs.

This is just flat out wrong. Section 551 imposes a 5.4% surcharge on “modified adjusted gross income” that exceeds $1,000,000 for joint returns or $500,000 for those not filing a joint return. Corporations are exempt.

This tax is really aimed at individuals. The 2009 tax tables tax income above $372,950 at a 35% rate. This section means that income above $1,000,000 would be taxed at 40.4%. You will excuse me if I’m not going to cry over this. The implication that somehow taxing the money being taken out of a small business as individual profit is going to cost jobs is an argument I don’t find particularly compelling. This is just another example of Republicans wanting to let the rich keep what they have at the expense of the rest of us.

Page 520Section 1161 cuts more than $150 billion from Medicare Advantage plans, potentially jeopardizing millions of seniors’ existing coverage.

This is an appeal to fear and a particularly disgraceful one at that. It attempts to frighten seniors into thinking that a huge number, $150 billion worth, of arbitrary Medicare cuts are being made that are going to take away coverage they depend upon.

These are adjustments made in an attempt to reform current Medicare issues. The $150 billion is an assertion not justified or mentioned in the bill itself. I’m not going to claim that these changes aren’t going to cause any problems. One can’t tell simply by reading the bill and that’s the key point.

I will say that virtually everyone has recognized that there are inefficiencies in Medicare and the American Association of Retired Persons (AARP) has ENDORSED THE BILL so it’s rather unlikely that any existing Medicare coverage is going to take a hit.

Page 733Section 1401 establishes a new Center for Comparative Effectiveness Research; the bill includes no provisions preventing the government-run health plan from using such research to deny access to life-saving treatments on cost grounds, similar to Britain’s National Health Service, which denies patient treatments costing more than £35,000.

The bill makes no provisions preventing the government-run health plan from using such research to develop procedures for torturing puppies either. This is another appeal to fear which attempts to resurrect the specter of “death panels” without using the term.

This is total bullshit that should be ignored altogether and Garrett should be ashamed of approving such a statement for publication.

Page 1174 - Section 1802(b) includes provisions entitled “TAXES ON CERTAIN INSURANCE POLICIES” to fund comparative effectiveness research, breaking Speaker Pelosi’s promise that “We will not be taxing [health] benefits in any bill that passes the House.”

This is also accurate but misleading. The implication is that the tax is on benefits which it isn’t.

The tax is on insurance policies and is based upon a per capita allocation. The tax is levied upon the issuer of the insurance policy and not the policy holder.

Yes, but, I hear you say; they’ll just pass it on in increased premiums won’t they? Well, perhaps. Would you like to know what the default amount is per policy? It’s a stinking $2. You lose more than this in dropped loose change you don’t bother to pick up.

Ok, enough throwing rocks at Scott Garrett. He honestly has concerns associated with out of control government spending and high taxes. I share the same concerns so I’m not going to criticize him on principle but I do think he could have done a more factual analysis without the innuendo and fear mongering.

Let’s get down to the bottom line shall we.

The bill clearly does some good things. It establishes minimum requirements for policies, establishes an advisory board, establishes the Insurance Exchange, extends dependent coverage, eliminates lifetime limits and protects health screenings and preventive measures.

It also adds a range of taxes the most difficult to assess being the payroll tax on employers that choose not to provide insurance. Couple this with the “public option” and the dynamics aren’t obvious.

Most employers, there are exceptions, but most employers, want to do what’s right for their employees. Let’s not forget however that staying in business is at the top of that list.

The bill broadens benefits. This might be offset in the long run by more people acquiring insurance but in the short term I suspect it’s going to drive premiums up. That could very well make providing insurance no longer tenable for some firms that are on the edge. The grandfathering clause will alleviate some of this but that grace period ends after five years.

It might actually turn out to be cheaper for some employers to terminate health care and pay the tax. As a matter of fact, for some really small businesses there wouldn’t even be a tax.

I have to believe that means that some Americans are going to lose the employer coverage they already have and be forced to buy individual coverage from the Insurance Exchange and I sort of suspect that coverage will be the bottom of the barrel with the Public Option at the bottom of the bottom. Most of these folks will be in the lower income brackets but I doubt they would see any premium increase because they will probably be eligible for subsidies.

On the other hand, millions of Americans that can’t afford insurance now will probably be able to acquire it.

For those of us that can afford insurance and have it, I suspect that our coverage will improve but our premiums, at least in the short term, will go up. The question is by how much?

Overall I think the bill is pretty good. I’m a little concerned about the penalty and public option dynamics but the Lewin Report has alleviated that to some extend. If you believe them, the upheaval isn’t going to be that great but of course they’re only predicting about 50% of the uninsured problem will be solved as well.

Should the reform bill ultimately pass, I suspect there will be tinkering and adjustments for years to come. Twenty years from now, as a Democratic Congress and a gay Hispanic President argue over the latest round of recommended updates and improvements, the Right Wingers will probably be screaming “don’t you dare touch my health care with your socialist policies!”


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