10.19.2009

1500 pages and two aspirin might help a little...

I spent about an hour scanning/skimming the proposed Healthcare Bill -- I don't mean to imply that I read anywhere approaching 1500+ pages, but some features in the table of contents caught my attention. Here's some of what I read:
“SMALL EMPLOYER.—The term ‘small employer’ means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.” (from section 2230)

“LIMITED AGE VARIATION PERMITTED.—By age (within the standard age bands established under subsection (c)) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 4:1.” (from section 2204)

“DOLLAR LIMITATION.—The amount of the tax imposed by this section on any taxpayer for any taxable year with respect to all individuals for whom the taxpayer is liable under subsection (b) (3) shall not exceed an amount equal to twice the applicable dollar amount for the calendar year with or within which the taxable year ends.”

“CHRONIC CONDITION.—The term ‘chronic condition’ has the meaning given that term by the Secretary and shall include, but is not limited to, the following: A) A mental health condition. B) Substance abuse C) Asthma D) Diabetes. E) Heart disease. F) Being overweight, as evidence by having a Body Mass Index (BMI) over 25.” (from section 2104)
Some of this is fascinating to me. Most of it makes me either want to laugh or join a local militia. I'm sure, for example, Congress has good and justifiable reasons to limit age variation premium ratios to 4:1. Same goes for the BMI exceeding 25.

Of course, someone might argue that, "Well, the number has to be something," and point to statutory issues like the age of consensual sex (Why 18? Why not 16? Or 21?)... the difference here is that this bill is supposed to be calculable, which obviously necessitates having a close estimate as to how many Americans have a BMI over 25. Further, legislation like this cannot possible take into account the fact that some very healthy people have a BMI over 25. Mine's 23.7, for the record, and I exercise 5+ days a week, eat vegetables for dinner every night, and usually don't exceed 2400 calories a day. 5'11", 170lbs. Three pounds heavier than when I graduated high school as a three-sport athlete.

Yes, if we're going to legislate at this level, we need lines in the sand -- but the arbitrariness of it (the numerical definition of "small business," for example) is absurd enough to warrant, at least, a little teasing.

*Note: Yeah, I forgot to source that third one as I was copying it from .pdf file... then I lost it and couldn't find it again. Wishydig, don't even think about asking me to be more careful with my sources. Not this time, buster.

11 comments:

Wishydig said...

i don't think you're allowed to call yourself a three sport athlete if one of those sports was golf.

Casey said...

HAHA! Right on!

Wishydig said...

and the ridicule of any legislative language is fair. it's all pretty ridiculous.

remember too that this language is not creating false categories and choosing arbitrary boundaries. it's mimicking them. all these limitations and thresholds already exist at the hands of insurance industry. legislation will not just get rid of them, that's impossible. but it will try to make them more workable. well, good legislation won't just try, but succeed.

speaking of sources, you call this "the" proposed bill. do you mean the baucus bill? go ahead and make fun of it. many democrats are unhappy with it. precisely because it doesn't do much to improve the standing service. a lot of criticism went towards his office because of elizabeth fowler's presence.

Casey said...

Yeah, Baucus, I think.

I heard yesterday that Medicare led the league in denying coverage last year... I don't know if this is a reliable source or not, but:

http://healthcare-economist.com/2008/06/30/medicare-more-likely-to-deny-claims-than-commerical-health-insurers/

I can't find my source though. But this is what makes me nervous: how broadly will the public plan cover health needs? Will it cover artificial spinal disks? Colonography screening? Who decides? Here I don't mean to imply that "money" and markets were better at rationing... but they at least had a "logic" to them (i.e., you get care if you have good coverage and/or money). Under a more universal gov't program, who decides how far these "rights" to healthcare go? If the Secretary is able to define terms AFTER the bill is written, how are they figuring out the cost of the bill before it passes?

In other words: just how good will gov't healthcare be? They can make it as good as they want, you realize, right? It's just a matter of cost. At (say) an operating budget rate of 1 trillion dollars over ten years, would it be good? Would it be better at an operating budget of $2 billion? 'Cuz government can make that happen.

Also, when I was 20-years old, I decided to go into teaching primarily because I heard it had awesome health insurance, and I knew that the inhalers and skin medications I was using would've cost a bloody fortune if I didn't have awesome insurance. So I made that choice -- earned it, you know? Now I'm a little pissed, frankly, that Joe the plumber is going to get coverage on my dime.

Well, sorry... that got off the tracks. And yes, certainly all legislative language is easy to ridicule. Consequently, those who legislate more, will receive more ridicule from me.

Wishydig said...

that's a pretty fair presentation of some statistics. and i can probably go along with him in the warning of absolutes with his closing thought that these numbers help

"dispel the myth that the government is simply a benevolent entity, while commercial insurers are ruthless, profit-hungry wolves."

it's true that the truth lies in between. but that still doesn't implicate the government as being in any way worse than commercial insurance. the bias of the sample set it enormous. every medicare recipient is a senior citizen. every. one. it's a good thing he notes this in his analysis. it needs more attention.

the U-M hospital in ann arbor doesn't have a great 'success' rate among hospitals around the state. why is that? because they take predominantly difficult cases and they mostly take the patients that have tried everything else and have gone to U-M as a last resort.

but i wonder why so many people still insist on going there when their chances of survival are better elsewhere?

that's not a small bias. it's a huge bias. one that makes that line of comparative analysis exceedingly difficult. nothing i'd want to base an argument on.

re: the clean logic of money=coverage. not so.

what of the guardian insurance company that was stuck paying a ian pearl's muscular dystrophy bills. sure. it was a huge amount. but that's why he had insurance. until they simply decided that they weren't going to offer that plan to anyone.

no one is thinking they'll get muscular dystrophy so they don't see this as a liability in a company. no one thinks that they'll be in a position ask so much of insurance. so everyone feels safe. and huge companies have the power to do this because they can absorb the bad press especially if they're the only game in town.

rescission is an abused practice that health insurers are not willing to give up. the policy is horrible of collecting fees for years and only beginning background checks when the policy is called on.

it's a complete denial of one side of the contract on pure technicalities. and not fair ones. typos and slight discrepancies in the records and unreported minor pre-existing conditions that void the policy are a legal way for companies to deny coverage. reform needs to limit the time that a policy can sit unexamined before it is picked apart for the possibility of denial.

of course they have to protect themselves against fraud, and that should be their right. i would argue that the gov't should also have that right if it offers insurance. but if a provider sits comfortable and collects, it should be forced to sit uncomfortably and pay. no fair putting off the background checks just because it might stem the cashflow.

this is where regulation would be a good thing. because it would be great if the formula was true that "you get care if you have good coverage and/or money." as it is (let's put a public option aside for this point) insurers are free to take care of their own benefit according to that plan. and to screw the customer.

who's going to regulate that? the market? it hasn't. it won't.

we're both allowed tangents, right?

Casey said...

Yeah! -- I hope you're still here, because I feel like we're nearing a moment of synthesis here, Wishydig.

I'm with you, and I accept your analysis of the "huge bias." And I do think you understand what I'm asking about when I say "who will decide?" Cases like Ian Pearl's sound awful, but are you implying there will never be any more Ian Pearls under a government program? If you are, I'm still with you -- but then I'm veryveryvery skeptical about the idea that all of this is within a reasonable number when it comes to cost. To cover everything without exception would break the bank, wouldn't it? Or am I wrong?

What I fear in this string is not "big government," but democracy. What worries me is that the language of the bill will still be active even when a new Secretary is (re)defining the terms. If Republicans get elected on the notion that "our healthcare system is too costly" (listen for that in 2020), they will simply start ruling out certain diseases and disorders... and that may sound "cruel," but if the average middle-class tax payer is paying 60% by then, it might be necessary cruelty.

And you understand all of this. Right? I'm trying to be pragmatic here in my critique, and not ideological.

I have eczema, and a single tube of effective medicine retails for $220.00. I get one about four times a year. Similarly with my asthma, I take an inhaler that retails for $275.00. I get one a month. My BASELINE annual costs, just for maintenance, are over $4000.00. That doesn't include dentist visits, annual check-ups, etc.

Should the government pay for "itchy skin" for everyone? Is that a right? And, as Ayn Rand used to ask, "a right at whose expense?"

But anyway, I'm close -- I'm very nearly ready to say, "Okay, let's give this a try..." Sort of the same way I voted for Obama. I have no explanation for why I'm almost convinced, but I'm starting to trust my gut. (See my post on Ishmael, I guess)

Wishydig said...

i think i might have to appeal to an ideological argument at this point then. because i'm almost confident enough to ask you to stipulate that insurance companies are profiting more than they have to at the expense of service.

look at the presidents. they're fat cats. do they deserve to be? who cares? do they have to be? no. do i want to make it impossible for anyone to get rich? no. do i want to make it harder for someone to get rich? i doubt that i could. do i want to protect the wealth of the richest. not really.

that's heavy ideology i know. i think it's still possible to argue that gov't involvement could preserve the ability of the companies to provide service, while making it harder for the companies to use certain distasteful practices to protect profits.

you're right. there will still be ian pearls out there. something will get in the way of services in the most difficult of circumstances. but at this point i think it's fair to say that we simply want fewer cases like that.

i don't know why torte reform is such a hard sell for the democratic side. it should be part of the reform in favor of cutting spending. i don't know why the public option is such a hard sell for the republican side. it should be a part of the reform in favor of providing wider coverage.

and yes, both sides have to admit that they'll have to give up a little bit on their ideal goal. it will not reduce costs to zero. it will not lead to the best coverage for everyone. but it should put some coverage within reach for more people.

i can't ignore the story of my friend who dreaded moving back to the states from korea because he was able to afford some necessary medical care there and not here. how does korea do it? how does germany do it? how do so many other countries do what half of this country says is impossible?

my guess is that it's because it's not impossible.

i appreciate that you're saying it's possible, and that your question is "is it worth it?"

i guess i can't argue that for you. that's why the arguments so often go to anecdotal support. because no matter what, my stance requires that we make some millionaires sell a bentley or two and some professors pay more in taxes. just because i'm willing to pay some taxes for joe the plumber's coverage doesn't mean that i can in any way argue that you shouldn't be pissed off about it.

that's no longer an argument about legislation or policy fine print or even results. if someone just doesn't want to pay, not even the clearest promise of successful reform is going to going to convince them to be happy about it.

Casey said...

Couple follow-ups: I follow all of that except the part about CEO pay, which is just something that has never interested me--but let's argue that elsewhere.

I was thinking this morning about the fact that Gretchen has to drive an hour to find a place that has the H1N1 vaccine this Saturday, and then (I've heard) wait in line for more than an hour. Truthfully, I don't even know who's running that show anymore... is it the Health Secretary's job to get a vaccine to my pregnant wife? Is it my job? Is it my employer's responsibility? Is a private insurer responsible?

All I'm trying to iterate here is that this is a situation I don't enjoy -- when Gretchen's midwife tells her that 28 in 100 pregnant women who show up at hospitals with H1N1 die, and I'm somewhere between helpless and too-confused to participate in the prevention of that outcome... yuck. [Incidentally: why did all of my liberal friends make fun of the color-coded terror-alert system of the Bush administration while falling entirely for the dire warnings about swine-flu? Fear is a powerful motivator, I've heard.] Anyway, as Tracey Morgan said on "Weekend Update" last fall after the financial collapse: "FIX IT!"

I wonder if some/any of our conversation hinges on our relative positions with regard to healthcare needs and insurance coverage, etc.? My plan's pretty great, but my employer (the university) is running on fumes when it comes to a budget... colleagues are speculating that this private institution (at least) may find it more affordable to pay the fines for "de-insuring" its employees if there is a serious public option for its employees to fall into.

We're too far into the comments jungle now for this to do any good, aren't we? "I'll give you the last word..."

Wishydig said...

this'll be a patchwork comment:

"is it the Health Secretary's job to get a vaccine to my pregnant wife? Is it my job? Is it my employer's responsibility? Is a private insurer responsible?"

the problem would be believing that anyone in this list doesn't have some responsibility. all do.

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yes. at a hospital, 100 pregnant women were admitted and 28 of them died. but that's not a very relevant statistic. don't confuse that situation with the odds nationwide.

another source says that 4 in a thousand is more accurate.

for some reason midwives like to scare people.

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what liberal friends have you seen get all crazy about the swine flu? i haven't spoken to one person who thought it was a big deal. and when purdue told us to mention it in our syllabus everyone i talked to rolled their eyes. you're flinging tu quoque arguments out there too eagerly.

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"FIX IT!"

well we can all agree on that goal. and i think we've admitted it's just a question of means. at this point, i'm just more willing to believe that obama and sebelius and weiner and dean are truly looking for change in the direction of service than are aetna and blue cross. and i'm more willing to sacrifice what the former ask of me than what the latter ask.

at this rate, small employers are headed towards dropping coverage anyway. we're insulated from how bad it's been getting and how much it's costing them. but it would collapse anyway. and the same employers that might now have an incentive to drop insurance to leave you with the gov't plan were already on their way to that. but there'd be no plan for you.

are you sure the market would adjust to offer you something reasonable?

Wishydig said...

looking around i see that the 28/100 number was part of a report that has now taken all sorts of forms. including the report that 28 pregnant women since april have died of the flu.

but i can't find 28% mortality sources anywhere.

Casey said...

By "my liberal friends hawking H1N1" I meant Dr. Nancy and her MSNBC associates... whereas Fox treats it as an overhyped joke.

Also -- I just think, if we consider distribution of this vaccine as the FIRST task of our new government-backed healthcare system, I'm already disappointed. That's all I meant to imply. And it's not the midwife's fault: we called our hospital and they hadn't received a shipment yet. The FIRST task.

Blahblahblah, though... I trust Jesus more than I trust the government or the marketplace.