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And we are back. Yesterday I took a look at some of the Republican ideas for Health Care Reform, and while some of them aren't bad, some of the ideas I have learned are already essentially being done, and others are pretty much pure bullshit. But surely the ideas that President Obama has presented are all wonderful right? Right? Uh, well, not exactly.

Now of course what has some people pissed off right off the bat is not mention of a Public Option, and continuing to push the insurance exchanges and allowing companies to sell across state lines. Something that I do not believe is impossible to manage in a way that is better than how it was managed when credit card companies were allowed to do business across state lines, but it is surely nowhere near as good as Medicare for all or a strong public option. And to be certain we should not stop for even a moment pushing for those things. But at the same time I think there is some potential good ideas in Obama’s suggestions that deserve to be looked at and judged for what they are, not for what they are not.

There are ten "titles" with multiple sub sections. I am going to go in order but I will not be excerpting every section, just those that I have something to comment on.

Before I start let me offer a universal caveat so I do not get too repetitive. Any idea that I opine sounds good, must always be taken with a grain of salt, because even the best idea can become a massive Mongolian Cluster Fuck if it is implemented poorly.

And now let’s dive right into....

Title I. Quality, Affordable Health Care for All Americans

"Nothing in this act or anywhere in the bill forces anyone to change the insurance they have, period."

Hmm. My question, is it still accurate that if you have insurance already say through your work that you would not be able to leave it for one of the exchanges? Or will that be changed?

"Americans without insurance coverage will be able to choose the insurance coverage that works best for them in a new open, competitive insurance market – the same insurance market that every member of Congress will be required to use for their insurance."

I have to admit that I really rather like this sauce for the goose is sauce for the gander provision. I’m not holding my breath that it will make it through, but I can always hope.

"It keeps insurance companies honest by setting clear rules that rein in the worst insurance industry abuses. And it bans all insurance companies from denying insurance coverage because of a person’s pre-existing medical conditions while giving consumers new power to appeal insurance company decisions that deny doctor ordered treatments covered by insurance.

Make it illegal for insurance companies to deny coverage for children because of a pre-existing medical condition;

Provide rebates to consumers from insurance companies when they spend a large percentage of consumers’ premiums on advertising, bonuses and other administrative expenses instead of patient care;

Review of unreasonable insurance premium increases and rebates if unjustified; health insurers with a pattern of excessive rate increases can be blocked from selling through new insurance exchanges;

Remove arbitrary lifetime or yearly limits on coverage so people know that all of the care they need will be paid for;

Prevent insurance companies from dropping insurance coverage when a person gets sick and needs it most."

Frankly there is part of me that thinks that even if they manage to get this passed and give it some real teeth then something substantial will have been accomplished. It would still have us a long, long, way from being where we need to be, but it would definitely be a huge step in the right direction.

"Americans with pre-existing conditions will finally have the choice of quality, affordable insurance through a new insurance pool;

Small business owners will be eligible for billions in tax credits to help offer insurance coverage to employees;

Paperwork reduction and simplified forms will begin to reduce costs for doctors, employers and consumers;

New plans will have to offer preventive care and immunizations at no cost;

New plans will have to cover an enrollee’s dependent children until age 26;

A re-insurance program for employers that offer health insurance to their early retirees will save as much as $1,200 for every family enrolled.
   
A new website to help consumers compare different insurance coverage options along with state-by-state health care consumer assistance and ombudsman for any of their health insurance questions;

Public disclosure by insurance companies of the amounts they spend on administrative expenses including advertising, profits and salaries compared to what they spend for care.

Clear and easy-to-understand insurance documents to help Americans make decisions when shopping for health insurance;"

Again some really good ideas, and one that is very very good, and that some people will malign and deride as not that important. The simplifying of paper work. Now I no it’s no Public Option (Only The Public Option is The Public Option! Accept no substitutes) but it would save time, it would save money, and it would save people incredible amounts of stress. I recently was involved in a health care situation and the number of times that I had to recite medication list, patient history etc was pretty much ridiculous. The worst was having to repeat all this information at the general hospital that we had just given to the specialty clinic that was associated with the hospital and located just a few hundred yards away. The amount of stress this puts on people during a health crisis in incalculable.

Another great idea is to have new plans provide immunization and preventative care (I’m assuming they are meaning things like annual check ups, screenings etc.) and I’d love to see it even go so far as to make it free or low cost to do what Bill Clinton did which is to see your doctor when you first suspect a problem, instead of waiting and trying to ignore it.

"The Act asks everyone to take responsibility for improving America’s health care. In order to lower costs for all Americans and extend coverage to people with pre-existing conditions, all Americans who can afford to purchase insurance will be asked to.

Those who are uninsured add over one thousand dollars to the average premium of families with insurance. This added cost covers emergency room care for Americans without insurance. To help bring costs under control for all Americans and cover all Americans with pre-existing conditions, all Americans who can afford insurance will have the responsibility to purchase it."

Now this part I don't like one, bit. Personally I think it's absolute bullshit, but if you are going to insist on it, I would say that it should be attached to a trigger. Then if in ten years there aren't enough people buying insurance, AND the insurance companies are keeping their end of things up, then and only then would the individual mandate kick in. Frankly I think that most people are willing to buy insurance from companies even if they would prefer a public option, single payer, or medicare for all, so long as the coverage is affordable and provides real value, not just vaporcare.

"Individuals and families are eligible for a waiver from the requirement to purchase health insurance if coverage is unaffordable – if premiums exceed 8 percent of income.

In addition, exceptions are made for religious objectors, taxpayers with incomes below the tax-filing threshold ($9,350 for a single or $18,700 for a married couple in 2009), and Indian tribe members.

Americans under the age of 30 and other Americans who are exempt from the requirement to purchase insurance are eligible for a low-cost catastrophic plan that covers serious illness and injury."

Most of these ideas are decent. Although I'm not a fan of the religious out, but I accept it. I also like the idea of the catastrophic plan option for those who are exempt, although more information would be nice about what exactly it would cover etc.

"Larger companies that offer coverage must automatically enroll any new eligible employees. Any company with 50 or more employees that does not offer coverage and whose employees access taxpayer supported health programs will be required to help offset the costs to the American taxpayer.

No small business owner will be required to enroll an employee or to offset health costs to taxpayers. As mentioned earlier, small business owners will receive incentives to cover employees through tax credits and enjoy greater buying power and insurance choices in the exchanges."

Most of that is alright, although I have to admit that personally I'm not a fan of automatic enrollment. I'd rather see the law made so that companies that provide insurance have to keep in a state of open enrollment. This would allow employees to switch to the employee plan if they already have insurance, or would give them time to comparison shop and then choose.

Title II. The Role of Public Programs

"Beginning in April of this year, States will be allowed to expand Medicaid eligibility to more individuals. Starting on January 1, 2014, all low-income, non-elderly and non-disabled individuals will be eligible for Medicaid. This includes unemployed adults and working families – all people with income below $29,000 for a family of four (133% of poverty).

The Federal Government will support States by providing 100% of the cost of newly eligible people between 2014 and 2017, 95% of the costs between 2018 and 2019, and 90 percent matching for subsequent years.

All states will be treated equally and will not receive any special matching rates under this provision.

"Hmm. Okay, so instead of Medicare for all Medicaid for more? I’m sure the last bit about no special rates for some states will piss of a lot the GOP.

"Individuals will be able to apply for and enroll in Medicaid or CHIP through streamlined, easy to use, State-by-State websites. These programs will coordinate procedures to provide seamless enrollment, save time and lower administrative costs."

Again, this might be a small thing, but I would say that anything that can make dealing with this stuff less confusing for people is a good thing.

"Medicaid beneficiaries with disabilities who would otherwise require care in a hospital, nursing facility, or intermediate care facility will have a new option offered by States for community-based attendant services and supports. The Federal government will offer increased assistance for States who offer these community-based services.

States will be allowed to provide home and community-based services and full Medicaid benefits to people with long-term care needs. They’ll be allowed to extend the "Money Follows the Person" rebalancing demonstration, protect recipients of home- and community-based services against spousal impoverishment and increase funding for State Aging and Disability Resource Centers."

I think these are some wonderful ideas. While I understand that there will always be people who's needs are so intense and vast that caring for them in their own homes and communities is not realistic, the more people who can be kept out of institutions often hundreds of miles from their friends and families, the better. It is not to disparage such institutions, but people want to be where they know and are known, not in the company of strangers.

"The government will save money with increased rebates on prescription drugs furnished under Medicaid. The rebates will increase from 15.1 to 23.1 to more accurately reflect market prices and discounts typically provided by drug manufacturers to large volume purchasers. Drug manufacturers will also be required to extend these same rebates to new drug formulations and Medicaid managed care organizations."

Well it sounds like this is meant to redress the bullshit corporatist nonsense from several years ago that crippled Medicare's ability to negotiate lower drug prices. At least I’m hoping that’s what it will mean.

Title III. Improving the Quality and Efficiency of Health Care

"In 2010 seniors who reach the "donut hole" will receive $250 to reduce the cost of their drug purchases. Over 8 million seniors hit this gap in Medicare coverage, and for those who do not have other coverage, average drug costs are $340 per month, or $4,080 per year. Seniors who hit the gap in drug coverage are often chronically ill and many are forced to go without the prescription drugs they need."

Um, okay, spiffy, just one question. Is that $250 per year or per month? I know it may seem like a dumb question, but given the disconnect from reality that some government plans can sometimes have, I don’t think it’s a completely unrealistic one.

"Insurance companies will be required to offer Medicare Advantage plans at reasonable rates so that seniors are guaranteed the best benefits at the best price for all Medicare beneficiaries. They will be rewarded if enrollee satisfaction and quality of care are high. And MA plans will also be prohibited from charging seniors more than they would pay for services delivered under the traditional Medicare program."

Sounds reasonable.

Title IV. Prevention of Chronic Disease and Improving Public Health

This section honestly if fairly light on ideas. Some bits about making the Center For Disease control more efficient etc, and then this chunk of well frankly crap,

"The Act will help to put American families in control of their own health decisions with nutrition and prevention information based on the best science, including a requirement that certain restaurants and vending machines post calorie information."

Because the problem is just that there isn't enough nutrition information. No the problem is that crap food in the immediacy is perceived as cheaper and it's easier to acquire. I've got a better idea. How about offering rebates for buying food ingredients instead of ready to heat foods? How about rebates for planting a garden? Offering incentives and ways for people to eat healthier, instead of providing them more detailed information that frankly they either know and don’t care, or know and don’t feel like they have viable alternatives.

Title V. Health Care Workforce

"By funding scholarships and loan repayment programs, the number of primary care physicians, nurses, physician assistants, mental health providers, and dentists will increase in the areas of the country that need them most. With a comprehensive approach focusing on retention and enhanced educational opportunities, the Act combats the critical nursing shortage. And through new incentives and recruitment, the Act increases the supply of public health professionals so that the United States is prepared for health emergencies.

The Act invests in grant programs that support the training of primary care providers, including family medicine, pediatrics, general internal medicine, and physician assistantship. It also provides payment bonuses to primary care physicians.

The Act will increase the number of primary care providers, including doctors, physician assistants, nurse practitioners, and dentists in the areas of the country that need them most. Through the National Health Service Corps, the Act provides significant funding for scholarships and loan repayment for doctors, nurses and other providers who provide medical, dental, and mental health care in urban and rural areas that have a shortage of health professionals. It also increases the loan repayment amount and enables additional flexibility for providers to meet their service requirements.

It creates a loan repayment program for pediatric, mental and behavioral health specialists who provide services to children and adolescents in underserved areas or with underserved populations.

The Act also supports scholarships and loan repayments for disadvantaged students who commit to work in medically underserved areas and who serve as faculty in participating institutions."

There are similar provisions for increasing the pool of nurses as well. I think this is a great idea. For far too long there has been no attempt to offer incentives to make being a general practitioner as attractive as being a specialist has become, and it is way past time that something was done to redress the imbalance.

Title VI. Transparency and Program Integrity

"To give patients greater choices, doctors with financial interests in imaging services, like MRI services, must inform the patients in writing that they can obtain the recommended imaging service from a person other than the referring physician, and provide a contact list."

Nope. Totally wrong. This provision is wholly unrealistic. Instead of giving people who are either sick and worried about their problem, or their family something else to have to deal with, why not simply make it illegal either for a physician to have an interest in such a service, within a certain mile radius, or illegal for him to refer patients to any service that they have an interest in. Why give people one more thing to have to think about.

"To prevent conflicts of interests and insure full transparency and information for patients, the Act requires all drug companies, device, and medical supply manufacturers to fully disclose and report any gifts they make or financial arrangements they have with doctors, a physician practice or group.

All pharmacy benefit managers (PBM) that manage the prescription drug portion of health plans under Medicare or the Exchange must report information regarding any rebates, discounts, or price concessions they negotiate for prescription drugs. They’ll also have to report often they use generic drugs rather than more expensive brand name drugs, to ensure more accurate payments for their services and keep health care costs down."

Great idea, and let’s make sure that there is one single website to go to for this information so that way people don’t have to try and hunt for it.

Then there are some commonsense ideas about better training for nursing home staff, requiring background checks etc. Also some more of the reforming medicare to cut down on fraud, which while I’m sure is important frankly seems vastly over hyped compared to the need for oh say a public option, or keep insurance rates down to reasonable levels etc.

Title VII. Improving Access to Innovative Medical Therapies

"The Act promotes innovation and saves consumers money. It ends anti-competitive behavior by drug companies that keep effective and affordable generic drugs off the market. It extends drug discounts to hospitals and communities that serve low-income patients. And it creates a pathway for the creation of generic versions of biological drugs so that doctors and patients have access to effective and lower cost alternatives.

Ending Pay-for-Delay

Saves money for consumers and taxpayers by ending the collusion between pharmaceutical companies where companies with brand name drugs pay companies who make generic drugs to keep the generic drug off the market.

Extending the Discount Drug Program

The Act extends discounts on drugs to hospitals and communities that serve low-income patients.

Promoting Biologics Price Competition and Innovation

The Act creates a new pathway to create generic versions of biological products so that Americans have access to effective, lower-cost alternatives."

Hmm. Some good ideas, maybe some day drug reimportation will be part of these cost cutting innovations.

Title VIII. Community Living Assistance Services and Supports Act (CLASS Act)

"Establishing a Voluntary, Self-Funding Long-Term Insurance Choice for American Families

The Act provides Americans with a new option to finance long-term services and care in the event of a disability.

It is a self-funded and voluntary long-term care insurance choice. Workers will pay in premiums in order to receive a daily cash benefit if they develop a disability. Need will be based on difficulty in performing basic activities such as bathing or dressing. The benefit is flexible: it could be used for a range of community support services, from respite care to home care.

No taxpayer funds will be used to pay benefits under this provision. The program will actually reduce Medicaid spending, as people are able to continue working and living in their homes and not enter nursing homes. Safeguards will be put in place to ensure its premiums are enough to cover its costs."

An interesting idea, although it really sounds like a glorified no interest savings account. I would think that offering to pay a fairly high interest rate so long as the money was left untouched until needed, or the offer of a certain amount of matching funds might go over better with most people.

Title IX. Revenue Provisions

Frankly most of this part made no sense to me, and I'm a fairly bright person, so I have to wonder how a lot of working class people would fair trying to wade through it. There was one part that stood out though, and not in a good way,

"Under current law, workers who earn a salary pay a flat tax of 1.45 percent of their wages to support the Medicare Hospital Insurance (HI) trust fund, but those who have substantial unearned income do not, raising issues of fairness. The Act will include an additional 0.9 percentage point Hospital Insurance tax for households with incomes exceeding $200,000 for singles and $250,000 for married couples filing jointly. In addition, it would add a 2.9 percent tax for such high-income households to unearned income including interest, dividends, annuities, royalties and rents (excluding income from active participation in S corporations)."

Well the idea in embryo doesn't sound so bad, but 200K for singles and 250K for marrieds seems a touch low. And why the odd figure for marrieds. Most things seem to be based on X rate for single and X(2) for marrieds.

There is also a proposed excise tax on medical devices. My question is what is to keep insurance companies from passing that on to the consumer?

Finally Title X, is very short and is just about reauthorization of the Indian Health Care Improvement Act, which is great for them and I don’t begrudge it to them.

Well there you have it, the highlights. There are some good ideas, and I certainly hope that they make it into law. But I sure hope Obama doesn't think that this is going to placate us. If we should not let the perfect be the enemy of the good, neither should we let the good enough for now be the enemy of the even better in the future. Whatever is passed is going to be imperfect, so we must keep pressure on to improve it as quickly as possible.

Tomorrow I will hopefully be wrapping up with a look at the Healthcare Summit. Until then....

Keep The Faith My Brothers And Sisters!

(This article originally appeared at The One About...)

Originally posted to Toriach on Wed Feb 24, 2010 at 06:59 PM PST.

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