I followed the debate and the vote from the House of Representatives yesterday largely because it was the most significant piece of legislation in probably 40 years, it will affect me and my friends/family, and because I am a supporter of healthcare reform. So, does that mean I support the bill passed last night (HR 3590) and its amending bill, which was also passed?
More importantly, should YOU be happy about what happened?
Today, the news if filled with opinions on how the sky is falling, America is doomed, we're all living under the tyranny of an oppressive government, etc. This, of course, is unanimously the opinion of conservative commentators. Liberals are all patting themselves on the back and saying how awesome they are. Who should you believe?
From my perspective (and that is the perspective of a working scientist who reflexively doubts everything, whose political views are socially liberal and fiscally conservative, and who voted for Barack Obama in the last election), the passage of the bill is mixed, but positive. It's socially progressive, and according to the Congressional Budget Office (nonpartisan), the bill is funded and decreases the deficit over the next ten years, which one might think satisfies the wants of a fiscal conservative. Here's the problem: it's not acceptable practice in this author's opinion to run up a massive deficit and then pat yourself on the back because you're spending less of the money you don't have. A deficit is a deficit is a deficit.
But, it's an improvement over the deficits accrued by the previous Republican administration. Healthcare is a necessity, and cannot be simply cut from consideration any more than national defense could. I HATE the "it's better than nothing" approach, but we've got to have it.
One needs to be aware that, while this bill cuts the deficit over the next 10 years, some of its provisions will not go into effect until 2014. Therefore, the case can be made that there are 10 years of funding (and taxes) for only 6 years of benefit. When HR3590 gets signed into law tomorrow, some provisions are immediate: prohibition of some of the more egregious insurance practices will be immediate (caps and pre-existing conditions being the big ones); children will be retainable under parental insurance until age 26; and the Medicare Part D "doughnut hole", which I have had extensive experience with as a pharmacy employee, will get some lip service to try to close the gap.
I think there is almost universal support for the insurance regulatory aspects of the bill (patient's bill of rights, as it's been called), but the effect on rates for existing customers remains to be seen. I have no information on that, as of this moment, but I can hardly see how they wouldn't go up without legal prohibition otherwise; there is no such prohibition that I am aware of. The extension for children affects me directly, as I lost my health coverage when I turned whatever age it was and could no longer be carried on my mother's plan. I can't afford my own insurance, as I make only ~$12,000/year. However, I don't believe it's proper for my parents to support me any further at this stage of my life, so I have no real love for this provision. As for the "doughnut hole", the $250 check seniors will get to help close this gap is laughable at best. That's one script for a
statin (cholesterol drug), which seniors are almost universally prescribed, before that money is gone, gone, gone. This is lip service and nothing more until the later provisions for price regulation go into effect. I believe there have been negotiations with drug companies to lower the cost of prescription medication, and that will make a real impact.
As of 2014, this bill requires that Americans purchase health insurance. If you think this is un-American, pull your head out of your ass and realize the irony of having to buy car insurance, but not cover your health. Here's the key to understanding insurance: buying power is determined by the number of enrollees in a potential insurance market; the more people, the more buying power, and subsequently the lower the cost. It's like Wal-Mart and the mom-and-pop corner grocery store: the little guy simply cannot compete with a multinational corporation because they don't have the buying power to pass any savings on to consumers. Call it the "economies of scale", if you like. Requiring coverage of everybody further addresses one of the primary issues driving up the cost of health insurance for the middle class: the uninsured. If everybody is covered, the middle class will pay lower premiums because they no longer have to subsidize the costs of uninsured sick people. Uninsured sick people were presumably uninsured because they couldn't afford it, so this bill is intended to provide large pools for low-income families to buy into, thereby actually giving them some power in the market. There are also tax credits for these people, as well as credits for small business owners to provide coverage to workers, again as part of national pools which are not in existence today. So, who pays more?
Individuals who do not purchase coverage will be subject to a tax of 1 or 2% of income or a flat fee, whichever is higher. Businesses who do not provide coverage will pay a fee, also. Small small-business [sic], like my father's business, for example, would be exempt due to size of payroll. Otherwise, they are looking at 8% (or less, depending on size) of payroll in fines. The rest comes from Robbing Hood. That's right, the rich get fucked to pay for the rest of us. That's the price of being rich in America. For the record, I'm poor, but I don't think it's right to penalize success to the degree we do in this country. Some numbers popularly floated around are that, if you figure in all the taxes/fees people have to pay (property, income, consumer taxes, etc.), it's not an exaggeration to say that $0.50 out of every dollar earned is not ours to keep. Some of that is federal, some is state, but it's taxes all the same. And, of course, the top 1% of earners pay around 40% of all income taxes. That, my friends, is socialism. As Colin Powell aptly pointed out, however, taxation is a form of income redistribution no matter how you look at it, and therefore is socialist in nature. The question then becomes to what degree. We all agree that we're part of this country, and that requires us to buy into it, and that is intended as a social contract for the benefit of everybody, and that's fine. But damn, there is such thing as the tyranny of the majority, particularly when you're sticking it to the wealthy.
Now, having said that, I'm of the opinion that it is a moral imperative for the wealthy to use their money for the good of the disadvantaged, but that's not a political position. It's simply a statement that if I had the money, I'd do what Bill Gates does. But, I'll remind everyone of the aphorism, "you can't legislate morality," nor should we. We'd all do well to remember that the wealthiest
Americans are the ones who create most of the jobs in this country.
So, there's the money. Because we're considering a healthcare bill, it makes sense to consult with healthcare professionals in rendering an opinion. What do they think? The
American Medical Association is in favor of yesterday's legislation, but with a couple of caveats that I share. First, medical costs can be reduced by regulating the liability of doctors and hospitals. Something like 25% of procedures and 10% of hospitalizations are due to "defensive medicine", i.e. practices intended to reduce the likelihood of lawsuits due to poor patient outcome. We spend twice as much on healthcare as we really should in this country (16% GDP instead of 8%, which is more of a national average), so litigation reform would go a long way to cutting costs. This bill does nothing to address this issue, and I support addressing it.
The AMA demands the repeal of the current physician payment formula used to calculate reimbursement. Originally, a provision was in place in the bill just passed to address this issue, but was removed because it would've INCREASED the deficit over the next ten years, rather than decreasing it. Basically, doctors/hospitals are being cheated on Medicare to artificially cut the cost of HR3590; that means that those costs will be passed along to the middle class, and we are still working against ourselves. BIG fail on that one. Physicians stand to lose 21% of reimbursement revenues in the immediate future.
The bill does purport to cut costs by other means, besides stiffing doctors for Medicare patients. Administrative costs claim to be a big gain, e.g. electronic systems, more open access, insurance streamlining, etc. Quite frankly, if you can make a real dent in this monster of a healthcare system by changing how people push the paper, I don't have the imagination to see how. The AMA does support this, however.
The AMA supports provisions in the bill to eliminate copays for wellness exams. It stands to reason (and analysis) that keeping somebody well costs less than pulling them back from the brink after an emergency room visit that came almost too late. A dime of prevention is worth a dollar of... well, trying to cure them after the fact, I guess. This WILL cut costs, I support it, and it is addressed in the legislation.
So, where is the opposition coming from?
Republicans have no thoughts of their own, they have only the thoughts of Rush Limbaugh and the disgusting turd Sean Hannity (at least if they're from Texas). I know, because I was young and foolish once, too. They all think the end times are upon us, just like every election when the victory for the opposing party is an acute sign of doom. Funny how it never seems to be. I'm not going to claim to be an independent, because that's a goddamned cowardly grab for credibility when you're talking about a partisan issue; the best I can claim is to be a Democrat who doesn't agree with his own party some of the time because membership is restricted to politicians, and they spend too much fucking money (e.g. the bailout, although that was supported by BOTH parties; where's a guy to turn?). It is an empirical fact, however, that Democrats in my lifetime have been more fiscally responsible than Republicans. Period. So, this bill was passed unilaterally (the opposition was, in fact, somewhat bipartisan by the vote count), and that is a concern for me. It should be for you, too, and probably is another source of opposition from average citizens. However, there are some 200 Republican amendments in the legislation passed yesterday, so the bill was bipartisan in content, if not support.
At some point, people may come to grips with the fact that Republicans have always tried to kill healthcare reform (remember the early nineties? Clinton tried to get it done, but was thwarted by Gingrich and the Republican congress.) because the success of such a piece of legislation would be political armageddon for the Republicans. It's better politics to fear-monger and oppose, oppose, oppose, despite the fact that it turns the stomach of people like me.
So, should you be happy? Afraid? Skeptical? Yes.
This will not be a smooth road, I guarantee. The system will undergo legislative revision in the years to come, I guarantee. Will it turn out for the better? I believe it will, even if for no other reason that this: it pushes the stagnant status quo such that we WILL find a new, better equilibrium at some point. The politics of the situation will continue to cloud the issue. The legislative process, I'll remind you all, is also not done. The Reconciliation bill will have to go back to the Senate, and there will be a strong push by the Republicans to repeal. They will send letters, they will spit on congressmen, they will have demonstrations. It may even look on television like everybody hates this thing. But, you know what? Most people, like me, like you, we aren't all that sure. We hope, but it's in our nature to doubt. But the analysis presented here stands to reason for the average guy. I can't read through a 2500-page piece of legislation, because I've neither the time nor the inclination. Neither can you, I'd imagine. Most of us probably feel like it's a strong sign that this is a bad idea, just because the damn thing is so long.
All of us are neophobes when it comes to Washington. That's to be expected. Nevertheless, I'm at least optimistic.
Note: Some of the numbers and such presented here might be from older versions of the legislation, depending on where I picked them up. I would note that I'm really making a qualitative argument here, rather than a quantitative one, anyhow. As such, I haven't bothered to make citations or quote sources save for the AMA, all of their views which can found on their website. This is also not a heavily composed opinion, and is rather the product of one sitting and one guy's opinion on the subject.
The entire budget/deficit situation is bigger than healthcare, and beyond the scope of this post. I have avoided my usual refrain when money issues for things I want (e.g. NASA, healthcare) creep up, which is "How much money have we spent in Iraq, again?" and "How much was that bailout? Over a trillion dollars?"
For full disclosure, I am a supporter of single-payer healthcare in this country. This approach maximizes the size of the pool and cuts administrative overhead to the theoretical minimum. This is NOT, however, what this legislation does.
Additional Note: This legislation eliminates the ability of insurance companies to discriminate against women by charging them higher premiums. As has been noted elsewhere, insurance has long considered womanhood as a "pre-existing" condition.
As of Monday, March 22, 10 states are planning to sue on the grounds that the healthcare bill is unconstitutional.